why we should decriminalise personal possession of all · pdf file6 major flaws in current...

David Nutt FMedSci Prof of Neuropsychopharmacology

Imperial College [email protected]

President European Brain Council Chair – Drugscience.org.uk

[email protected]

Why we should decriminalisepersonal possession of all drugs

Addaction lectureLondon 2017

Once upon a time...

Saying what I will say today once got me sacked!

Oct 30th 2009Sacked as government chief advisor on drugs for saying cannabis less harmful than alcohol and so UK law wrong

But now know I was right…..

Obama agrees with Nutt!

Marijuana no more dangerous than alcohol

Terminology

• Criminalisation - drug use/possession is a crime that can be punished by criminal sanctions including the death penalty in some countries

• Depenalisation/Decriminalisation – means NO criminal sanctions – but civil sanctions can apply e.g. fines/witholding driving license etc - often with dissuasion processes to reduce drug use – cfPortugal for all drugs Holland for cannabis

• Legalisation – means anything from a fully open market = drugs sold to anyone - to a regulated market with age and safety limits

= as with alcohol and tobacco in UK today

Key questions re drug laws

• Are they proportionate to relative harms? - Drugs and other activities e.g. horse riding

• Do the “benefits” of the laws i.e. presumed reduction of use/harms outweigh the downsides e.g. reduced research and treatment?

• Do they work? i.e. do they reduce drug use and harms?

Why decrminalisation is the right approach

1. It avoids the massive damages criminalisation produces

2. It is proportionate to the health harms of drug

3. It greatly facilitates research and clinical innovation

4. Evidence e.g. from Holland and Portugal prove it works!

6 major flaws in current criminal punishment-based drugs policy

1. Is biased re drugs currently controlled = dishonest so immoral

2. Puts punishment above harm reduction – another moral choice

3. Punishments currently disproportionate to harms à more harm than good

4. Severely limits treatment and research

5. Encourages use of more toxic compounds

6. Wastes huge amounts of money

Current drug policy is biased

What is a drug? And who says?

NodefinitionintheUNconventionsnorintheUKDrugsAct

è Sothendefinitionslefttopoliticians,newspapersandthedrinksindustry...

§

What the drinks industry says

What is a drug? My definition

“something a politician once used but now regrets”

Jaqui Smith (ex Home secretary)

“I smoked cannabis but didn’t enjoy”

David Cameron

“I did things when young that I Ishouldn’t have – we all did”

etc etcRelease

Newspaper scare stories

LSD scares - even worse than the Sun over mephedrone !

Drugs ranked according to total harm

Nutt King & Phillips Lancet Nov 2010

Alcohol

Cannabis

Tobacco

Harm to Users

Harm to

Others

14

Alcoholu

Drug related deaths in UK

0

10,000

20,000

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40,000

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90,000

Tobacco Alcohol Opiates

Num

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ths

Personal communication based on pubic health sources from Professor D. Nutt, Psychiatrist and Edmund J. Safra Professor of Neuropsychopharmacology, Imperial College LondonONS. 2015. Deaths related to drug poisoning in England and Wales: 2015 registrations. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations#paracetamol-related-deaths-remain-stable-in-2015. Last accessed: February 2017.

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Tobacco Alcohol Opiates Melanoma RTAs Suicide AIDs

Num

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ths

Other preventable deaths

Personal communication based on pubic health sources from Professor D. Nutt, Psychiatrist and Edmund J. Safra Professor of Neuropsychopharmacology, Imperial College London Public health sources: Smoking and drinking among adults (2009) Office for National StatisticsDrug Misuse Declared: Findings from the 2010/11 British Crime Survey England and Wales. Home Office and Alcohol Fractions report Estimates of the Prevalence of Opiate Use and/or Crack Cocaine Use, 2009/10 Sweep 6 report. The Centre for Drug Misuse Research

~2,000 ~2,500 ~5,000 ~400

14

0

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16-24 25-34 35-44 45-54 55-64 65-74 75+Age group

Numb

er of

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30%

% of

all d

eaths

by

age g

roup

Wholly attributable conditions Partially attributable chronic conditionsPartially attributable acute consequences % of all deaths by age group

Figure 1. Number (% of all deaths in each age group) of male deaths attributable to alcohol consumption by

age and type of condition (2005)

0

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16-24 25-34 35-44 45-54 55-64 65-74 75+Age group

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eaths

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roup

Wholly attributable conditions Partially attributable chronic conditionsPartially attributable acute consequences % of all deaths by age group

Figure 2. Number (% of all deaths in each age group) of female deaths attributable to alcohol consumption by

age and type of condition (2005)

UK – latest dataMore than 20% of all male deaths 16-44 yrs due to alcohol

Male deaths from alcohol by age band

http://www.nwph.net/nwpho/publications/alcoholattributablefractions.pdf

Alcohol the most common reason for death in men under 50

20%

2014 > 1.2 million cases of alcohol related hospital admissions

13000 under 18s = illegal drinking

MDMA – 2000Cannabis - 700

NHS Cost = £3.5 bill

40% Scottish ITU beds occupied by alcohol-related illnesses

Alcohol = a major social cost

Deaths for people under age 65 from major diseases compared with 1970 - UK

Nick Sheron

Liver disease

The inexorable rise of liver deaths

80% due to alcohol20% viral

Note less than 2x increase in alcohol consmption over this period

12.20 12.20

5,49

4.39

6.66 8

The more you drink ! the more comorbid diseases you get – cause-specific relative risk by alcohol consumption

White et al. BMJ 2002;325(7357):191

0 10 20 30 40 50 60 70 80 Alcohol (units/week)





5.0

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lativ

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Lip, pharynx, and oral cancer

Oesophageal cancer Colon cancer Rectal cancer Ischaemic heart disease

Liver cancer Laryngeal cancer Breast cancer Essential hypertension Injuries

Ischaemic stroke Haemorrhagic stroke Cirrhosis Non-cirrhotic chronic liver disease

Chronic pancreatitis

Men and women Men Women

Blair government refused to act on alcohol because of this minor beneficial effect!

Wide impact of alcohol on human diseases

No correlation of UK Drugs Act or the UN Conventions with drug harms

21

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UK D

rugs

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sifica

tion

ISCD results

A

C

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linear r = 0.04

So the current UN Conventions and UK drugs laws are not evidence-based – so immoral (and illegal)

Current UN drug laws are politically driven

The Nixon 1968 campaign had two enemies: the antiwar left and black people.

We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities.

We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news.

Ehrlichman states

Did we know we were lying about the drugs? Of course we did

As did the UK government when they cracked down on cannabis users in the 2000s

Cannabis: a convenient political tool in UK

Riseinincidenceandprevalenceofcannabisusesince1970inEnglandandWales(Hickmanetal2007,Addiction102,597-606)

Everuse

PeriodprevalenceIncident

Cannabis<18

20x increase in cannabis users over last 40 years

Riseinincidenceandprevalenceofcannabisusesince1970inEnglandandWales(Hickmanetal2007,Addiction102,597-606)

Everuse

PeriodprevalenceIncident

Cannabis<18

20x increase in cannabis users over last 40 years

Q. But almost no deaths – so why is it illegal?

A. Politics – the USA demanded it

How to justify - Skunk - Driving risk- Schizophrenia risk

Alcohol much worse than cannabis on driving

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meta�analysis has helped to negate these methodological weaknesses. The DRUID

report (2011), after taking age, and gender and confounding factors into account and

controlling for traffic conditions, estimated that the use of cannabis increased the risk of

serious or fatal injury in a motor vehicle accident by 1�3 times. It was noted that

significant increased accident risk was apparent when the concentration of THC in the

blood was��5 µg/L, whether or not ingestion had occurred recently and regardless of the

origin of the drug (medicinal or illicit). For this reason and based on the evidence

(summarised above) available to the Panel, the threshold recommended in whole

blood for THC is 5 µg/L. At this concentration, the risks for involvement in, responsibility

for, or injury as the result of a traffic accident when driving under the influence of

cannabis are significant compared to a driver who has not consumed cannabis.

Cannabis and alcohol in relation to driving

The combined use of cannabis (as measured by THC) and alcohol produces severe

impairment of cognitive, psychomotor, and actual driving performance in experimental

studies and sharply increases the crash risk in epidemiological analyses (Ramaekers et

al, 2004). The risk estimate as an odds ratio (OR) for involvement in, or injury as the

result of a road traffic accident when driving under the influence of cannabis and

alcohol are shown below (Figure 4.1, adapted from Laumon, Gadegbeku, Martin, 2005).

Figure 4.1: Relationship between the odds ratio (OR) for the risk of a traffic accident

when cannabis and alcohol are detected alone and when alcohol and cannabis are

detected concurrently (adapted from Laumon, Gadegbeku& Martin, 2005).

Po

sit

ive S

am

ple

THC + EtOH

0.5 1 2 4 8 16 32

EtOH

THC

Odds Ratio (± 95% CI) 69

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DRIVING UNDER THE INFLUENCE OF DRUGS

Report from the Expert Panel on Drug Driving

K. WOLFF

R. BRIMBLECOMBE J.C. FORFAR A.R. FORREST E. GILVARRY A. JOHNSTON J. MORGAN M.D. OSSELTON L. READ D. TAYLOR

FEBRUARY 2013

Cannabis use increase in USA à reduced alcohol deaths on roads

Self-reportedcannabisuseandprevalence/incidenceratesofschizophreniaandpsychosesinEngland,1996to2005/06

0

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1996

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Annualprevalenceratesofschizophreniaandpsychosesper10,000PYE

Annualprevalencerateofschizophreniaper10,000PYE

Annualincidenceratesofschizophreniaandpsychosesper10,000PYE

Annualincidenceratesofschizophreniaper10,000PYE

Despite 20x increase in cannabis users, if anything, schizophrenia is declining

…..

Frisher et al (2009) Weissenborn and (Nutt 2011)

What about schizophrenia?

Targeting cannabis to reduce schizophrenia?

Topreventonecaseofschizophreniaonewouldhavetoprevent5000youngmenfromeversmokingcannabis

ACMD3rd cannabisreport2009

ThereforenojustificationtoreclassifytoClassB

Governmental dishonesty?

‘[Jaqui Smith…] My decision takes into account issues such as public perception and the needs and consequences for policing priorities. …

….Where there is a clear and serious problem, but doubt about the potential harm that will be caused, we must err on the side of caution and protect the public. I make no apology for that. I am not prepared to wait and see.’

But NOT when there are real facts about harm e.g. alcohol

What really happenedInadealwiththeDailyMail,inexchangefortheirpromisedsupportforLabour intheupcomingelectionPrimeMinisterGordonBrownagreedcannabiswouldbeupgradedtoClassBagainstACMDadvice

ANDnow1millionyoungpeopleintheUKhavecriminalconvictionsforcannabispossession!

à SeverelimitationofopportunitiesàUnderminesbeliefinjustice

Still the Daily Mail pushes its prohibitionist political agenda on cannabis

6 major flaws in punishment-based drugs policy

1. Is biased re drugs currently controlled = immoral

2. Puts punishment above harm reduction –another moral choice


4. Limits treatment and research



When masses of evidence shows harm reduction has huge health and economic benefits

Trend in number of years of imprisonment handed out by courts, 1994-2006

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1994

1995

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x (1

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100)

Drug offencesOther offences

Punitive drug measures fill our prisons

Six major flaws in punishment-based drugs policy







Punishments currently disproportionate to harms à more harm than good

Punishmentà deprivation

à drug dealing

One million UK men with criminal convictions for cannabis possession

3-4 fold over-representation of Black and Asian young men arrested despite same levels of cannabis use

A. Stevens (2011), Drugs, Crime and Public Health: The Political Economy of Drug Policy, Abingdon: Routledge

è an underclass that has few opportunities other than crime and drug dealing èincreased drug use

SIx major flaws in punishment-based drugs policy




4. Severely limits treatment and research 5. Encourages use of more toxic compounds


How cannabis has gone backwards

• Legal in UK till 1971– Banned as two rouge GPs were prescribing for recreational use– USA pressure to comply with their policy

• Much valued by Queen Victoria for gynae problems– J Russell Reynolds was her physician and was a

noted advocate of medicinal cannabis(Therapeutic Uses and Toxic Effects of Cannabis Indica,Lancet 1 (March 22, 1890) 637-683)

Scottish ex teacher in her 50s

Long standing Multiple Sclerosis- wheelchair bound – only cannabis provides relief

Front door smashed down in dawn raids by police on three occasions in past few years

à convictions for cannabis possessionmay go to prison

Cannabis - a century of dishonest policy when will we learn?

1935 “no medical use” by League of Nations - never revised by WHO ! – still Schedule 1 in UN

1961 Egypt and USA à ban under UN Conventions

1971 MDAct1971 – “no medical use” à Schedule 1

The worst excesses of the current laws

• In many countries opioids not allowed - even for pain control -in fact most of world population denied them

• In most countries (inc UK) cannabis not available for pain spasticity etc

• Psychedelics not available for anything anywhere

• MDMA also banned in most of world

• As all are in UN Schedule1 research largely blocked

How illegality affects scientific outputs

Made illegal

Structure identified

The worst censorship of research since …..

The banning of the telescope by the Catholic Church

1616 The papal Congregation of the Index banned all books advocating the Copernican system of explaining planetary motion -Not revoked until 1758

Galileo Galilei1564-1642

Giordano Bruno1548-1600

Nicolaus Copernicus1473-1543






5. Encourages use of more toxic compounds6. Wastes huge amounts of money

Encourages the use of more toxic compounds

Many many examples: in historic order • Opium smoking à heroin by injection• Alcohol prohibition à hooch and methanol• Cannabis à synthetics (spice)• Mephedrone à naphyrone• MDMA à PMA etc • LSD à nBOMs etc. • Heroin à synthetics e.g. AH7921 and now fentanyl

Number of drug-related deaths where selected substances were mentioned on the death certificate, England and Wales

0

10

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1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Novel psychoactive substances

Novel psychoactive substances

Rise of PMA/PMMA deaths following MDMA precursor clamp down

PMA

John Corkery Hugh Claridge Barbara Loi Christine Goodair Fabrizio Schifano National Programme on Substance Abuse Deaths (NPSAD) International Centre for Drug Policy (ICDP) St George’s, University of London, UK Drug-related deaths in the UK: January-December 2012 Annual Report 2013

Massive seizure of safrole in Thailand

Safrole (MDMA precursor) made illegal

PMA is sold as an alternative to MDMA

PMAMDMA

CHEMICAL STRUCTURES VERY SIMILAR

Production of MDMA (ecstasy)

MDMASafrole

From sassafras oil

Alternative precursors à different products

Anethole PMA

PMMA

From aniseed oil

Seizure of massive quantity of safrole in Thailand in 2008 àreduction in supply of MDMA

So underground chemists turn to other precursors such as aniseed oil

With disastrous consequences

Safrole MDMA

PMMA

PMA and PMMA

• Not typical stimulants • Slow onset of actions à overdose

• Block monoamine oxidase inhibitor so can get serotonin syndrome

à hyperthermia, brain damage and death

An example of how the “war on drugs” leads to collateral deaths.

Another example of wrong policies

Cannabis

Perverseeffectsofprohibitionoftraditionalcannabis

THCandCBD=

Traditional herbal cannabis or resin - equal mixture of d9THC and cannabidiol

Perverseeffectsofprohibitionoftraditionalcannabis

THConly=

Home grown cannabis à skunk – high d9THC and NO cannabidiol

Worse = Synthetic cannabinoids

More potent – more harmful - much less well understood - so why do we have them?

Synthetic cannabinoids = Opening Pandora’s box

Becausecannabisisillegalandusersareprosecutedandprisonersaretested

è (logically)seeklegalalternatives

And there are very many potential synthetic cannabinoids…

RCS-4 AB-001 XLR-11 5F-PB-22 ADB-CHMINACA 5F-AMB

heteroaromaticcore

alkyl substituent pendant

group

~2010 2015

T h e n e w e ngl a nd j o u r na l o f m e dic i n e

n engl j med nejm.org 1

From the Clinical Toxicology and Environ-mental Biomonitoring Laboratory (A.J.A., R.G.) and School of Medicine (A.J.A.), University of California, San Francisco, San Francisco, and the Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto (S.D.B.) — both in California; the Department of Emergency Medicine, Wyckoff Heights Medical Center, New York (L.I.); the Of-fice of Diversion Control, Drug and Chem-ical Evaluation Section, Drug Enforce-ment Administration, Springfield, VA (J.T.); and the Chemical Defense Program, Office of Health Affairs, Department of Home-land Security, Washington, DC (M.S.). Address reprint requests to Dr. Gerona at roy . gerona@ ucsf . edu.

This article was published on December 14, 2016, at NEJM.org.

DOI: 10.1056/NEJMoa1610300Copyright © 2016 Massachusetts Medical Society.

BACKGROUNDNew psychoactive substances constitute a growing and dynamic class of abused drugs in the United States. On July 12, 2016, a synthetic cannabinoid caused mass intoxication of 33 persons in one New York City neighborhood, in an event de-scribed in the popular press as a “zombie” outbreak because of the appearance of the intoxicated persons.

METHODSWe obtained and tested serum, whole blood, and urine samples from 8 patients among the 18 who were transported to local hospitals; we also tested a sample of the herbal “incense” product “AK-47 24 Karat Gold,” which was implicated in the outbreak. Samples were analyzed by means of liquid chromatography–quadrupole time-of-flight mass spectrometry.

RESULTSThe synthetic cannabinoid methyl 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamido)-3-methylbutanoate (AMB-FUBINACA, also known as MMB-FUBINACA or FUB-AMB) was identified in AK-47 24 Karat Gold at a mean (±SD) concentration of 16.0±3.9 mg per gram. The de-esterified acid metabolite was found in the serum or whole blood of all eight patients, with concentrations ranging from 77 to 636 ng per milliliter.

CONCLUSIONSThe potency of the synthetic cannabinoid identified in these analyses is consistent with strong depressant effects that account for the “zombielike” behavior reported in this mass intoxication. AMB-FUBINACA is an example of the emerging class of “ultrapotent” synthetic cannabinoids and poses a public health concern. Collabo-ration among clinical laboratory staff, health professionals, and law enforcement agencies facilitated the timely identification of the compound and allowed health authorities to take appropriate action.

A BS TR AC T

“Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York

Axel J. Adams, B.S., Samuel D. Banister, Ph.D., Lisandro Irizarry, M.D., Jordan Trecki, Ph.D., Michael Schwartz, M.D., M.P.H., and Roy Gerona, Ph.D.

Original Article

The New England Journal of Medicine Downloaded from nejm.org at STANFORD UNIVERSITY on December 26, 2016. For personal use only. No other uses without permission.

Copyright © 2016 Massachusetts Medical Society. All rights reserved.

Some prisons estimate up to 75% of inmates now using “spice” regularly despite their now being illegal

So what did the government do?

• Bannedallchemicalstructuresthatcouldbeusedtomakesyntheticcannabinoids

• Oops.....HomeOfficehadtoexemptover20medicinese.g.indomethacin!

• Itsbeenestimatedthatover100,000researchchemicalsinacademicandpharmaceuticalcentres nowillegal!

• Couldà endofpharmaceuticalresearchinUK!

http://www.drugscience.org.uk/blog/2017/1/4/an-unhappy-christmas-for-uk-research-how-the-law-against-synthetic-cannabinoids-might-destroy-pharmaceutical-discovery-in-the-uk

Number of drug-related deaths where selected substances were mentioned on the death certificate, England and Wales

0

50

100

150

200

250

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Cocaine All amphetamines

Safer drugs save lives – impact of mephedrone on cocaine deaths

Mephedrone: enters banned

John Corkery Hugh Claridge Barbara Loi Christine Goodair Fabrizio SchifanoNational Programme on Substance Abuse Deaths (NPSAD) International Centre for Drug Policy (ICDP) St George’s, University of London, UK Drug-related deaths in the UK: January-December 2012 Annual Report 2013

•

6. Wastes vast amounts of money

è Thewarondrugshascostovera$atrilliondollarsè Claimed>300,000livesè Destabilisedmanycountriesè Andhadnegligibleimpactonuse


Decriminalisation works

• Holland – Cannabis coffee shops set up to segregate soft and hard drug

markets– Worked exceptionally well– NO increased cannabis use – MASSIVELY reduced heroin use

• Portugal- decriminalised possession of all drugs for personal use- criminal record more damaging than drugs for non –addicted

users - addicted users are ill so punishment immoral – require

treatment

Portugal15yearspolicyimpactonheroinharms

Treatdrugusershumanely+therapyè 2/3reductionheroindeaths

UK– constricttreatmentavailabilityè 2/3increaseindeaths

è AndmuchlessEXPENSIVE!

In UK, black market continues to kill

Nov 2016 in KentRobert goes to score some cannabis

Gets offered “ecstasy” as well -- takes it

Dies as its fentanyl not ecstasy

Primum non nocere= First do no harmHippocrates 460-370 BC

Key principle of medical ethics

Should not the same principle apply to the law?

Time now to learn from medicine

Decriminalisation is the obvious way forward

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