A proposed shift in drug policy: From prevention to harm reduction

I recently finished Professor David Nutt’s new book, Drugs Without the Hot Air, on minimizing the harms of drug use, both legal and illegal. Professor Nutt’s tone is light and his writing is accessible to readers of all scientific backgrounds, but his message is an important one. He explores the history and culture surrounding many drugs of abuse, ranging from the popularization of caffeine and nicotine, to the original medicinal purposes for cocaine and heroin, to the widespread use of prescription stimulant drugs today. He also discusses previous governmental endeavors, both successful and unsuccessful, on limiting drug abuse. This includes the floundering War on Drugs waged by the United States since the Nixon administration, as well as the more effective reduction in tobacco use seen in the U.S. and U.K through smoking bans, higher taxation and tighter restrictions on marketing campaigns.

Professor Nutt also effectively explains the neurochemical mechanisms involved in many common drugs of abuse, again covering legal highs like alcohol and nicotine, as well as more commonly thought of addictive substances, such as cocaine and heroin, and newer experimental compounds like hallucinogens, ecstasy/MDMA and designer drugs. He goes on to articulate the harms and benefits associated with each of these substances, as well as why some of these chemicals are more addictive than others.

However, the real strength of Professor Nutt’s argument is in his rationale for sensible drug policy based on scientific results rather than political scare-mongering and media sensationalism. He cites his own extensive research on the varying degrees of harm caused both to the individual and society by different drugs of abuse, including his infamous comparison of the detriments associated with ecstasy use to those caused by horseback riding. His harm scale comprises assessments of the total amount of risk associated with each substance, including the potential for addiction and mental and physical impairment, as well as the damage caused to society through things like drug-associated crime and money spent on medical treatments and criminal containment.

Professor Nutt’s conclusions have caused sufficient controversy, as he claims that alcohol causes greater harm to both the individual and society than drugs like cannabis, MDMA and hallucinogens. Alcohol can be highly addictive, with users developing both physical and psychological dependence, and its use is associated with a number of severe mental and physical consequences, including death. Additionally, the harm caused to society through drunk-driving, alcohol-fueled assault and medical costs for aging users is severe. In comparison, hallucinogenic drugs have virtually no addictive properties, as they are slow-acting and cause a rapid increase in tolerance, meaning that immediate subsequent administration of the drug results in no increase in pleasure or effects. There are also virtually no hallucinogenic-related crimes reported, as these drugs typically increase feelings of empathy and tranquility rather than aggression. Finally, substances like cannabis and hallucinogens have very low risk for toxicity and cause few long-term physical or psychological side effects, particularly when used in moderation. Indeed, in many cases being charged with possession of the drug is far more detrimental to the individual and his or her future than consumption of the drug itself.

Thus, while labeling a drug ‘legal’ or ‘illegal’ has little bearing on its harmful or addictive tendencies, it does have far-reaching social and legal ramifications on the individual, as well as on the research opportunities and potential therapeutic applications of the substance. One such example is the surge in prescription drug use in the U.S., recently over-taking illicit highs as the most widely abused substance. Opiate-based narcotics like OxyContin can be highly lethal, particularly when combined with alcohol. They also have high potential for dependence, which is exacerbated when the drug is crushed up and snorted rather than taken orally. Different routes of drug administration can greatly affect the potential for abuse, with the faster the drug reaching the brain the greater the reward value associated with it. After all, everybody likes a little instant gratification. Injecting, smoking and snorting a substance all deliver the chemical to the brain within 60 seconds, whereas consuming a drug orally takes longer, as the chemical must be digested before it can reach the blood stream. As such, prescription pills of opiate-based pain killers have less abuse potential than heroin, which is most commonly smoked or injected. However, when these pills are crushed up and snorted their effects are much more rapid, and their potency and risk for abuse sky rockets.

The paradox lies in the fact that heroin, which is considered to be a more effective analgesic than morphine, is strictly banned, even for use in hospitals. However, substances that are nearly identical in chemical structure and abuse potential are legal and readily available to those with an ailing grandmother or friend whose wisdom teeth were recently removed. Of course this does not mean that these pain medications should be banned as well, but rather that there should be more careful restriction of these drugs. Similarly, substances such as medicinal marijuana, MDMA and hallucinogens could have beneficial therapeutic effects when used in clinical settings, such as for patients with a terminal illness or PTSD. However, because they are labeled ‘illegal’ any research on these substances is tightly restricted, and numerous people who may benefit from their use are unable to obtain them legally.

Therefore, one of the most important take-away messages of Drugs Without the Hot Air is that drug policy should be directed by scientific research and careful empirical evaluation of the benefits and harms of a substance, rather than a reactive emotional or moral response from politicians and the media.

(Thanks to Sam Greenbury for the gift of this book.)