Sunday, 23 December 2012

A legal high for your loved one at Christmas?

We live in a curious world. I was out doing my Christmas shopping yesterday and came across a legal high stall right in the middle of Glasgow's Buchanan Street. The packaging and brand title were lurid, the stall was huge - much bigger than any I'd seen before in a similar spot - and they were brazenly giving out free samples  of their highly addictive product to anyone who was curious.

You'd imagine I'd be furious at this attempt to ensnare the Glasgow Christmas punter, but I wasn't. I was quite content, and later on I was cursing my failure to pick up some samples for a couple of my good friends.

The legal high in question was of course nicotine, and the samples being handed out were of a particular e-cigarette brand whose name I don't remember. The arrival of e-cigarettes - and I suspect this is the first Christmas they'll be under more than a few Christmas trees around the country - is going to cause a great many people to do a great deal of head scratching as they ponder a great many difficult questions.

I keep writing the word 'great' perhaps because e-cigs are certainly great news for existing tobacco addicts. Cigarettes are hideously unhealthy. Nicotine for the most part really isn't (though I learned in a past life that high doses can turn mice temporarily into cute, immobile hand warmers). If we've found a way to deliver nicotine - and nothing else of concern - into the lungs of those who are addicted to it in a manner that is safe and appealing than we should be celebrating and promoting it's use to all those who are unable to quit their cancer sticks.

But who should be promoting their use, to whom, and how? This question needs to be asked with urgency. It's all very well weaning people off cigarettes with a cheaper, healthier alternative, but how do we as a society feel about non-smokers becoming smokers (vapourers?) of these new products.

This question is made more pressing by the observation of the promotional activity that is occurring across the pond. Here's 'movie star' Katherine Heigl puffing on an e-cig with David Letterman and using the words, 'But it's not bad for you. It's a fun addiction!' :
And here's a television advert telling people to "Take back your freedom with blu"

Nicotine is one of the most addictive of all drugs, so many people seduced by the likes of Heigl and the attractive blu man to use e-cigs as their first smoke/vapour experience will be surrendering their freedom and submitting themselves to an expensive habit. Maybe it's not as expensive as tobacco, but it'll still be an unnecessary and persistent financial pressure.

Should a substance with such addiction potential be marketed in such ways? I believe not. It's a harm reduction product that should be prescribed and sold in pharmacists or on regulated websites, after appropriate agencies have subjected the devices to rigorous safety tests. The stall on Buchanan Street should be an NHS, anti-smoking stall, helping people to start the new year "smoke" free, not a private company pushing unregulated, addictive legal highs to all and sundry.

But e-cigs do have to be available to the general public, and they should be more available than cigarettes. If I'm offered the trade of e-cigs being available in corner shops if tobacco products no longer are, that is a deal I would happily embrace.

Like so many drugs, the availability of safe nicotine might also be an excellent opportunity to better treat or prevent some very costly and traumatic medical conditions.

This is where the neuroscientist in me comes out. Schizophrenia and psychosis in alzheimers have been linked to the alpha-7 nicotinic receptor gene, nicotine improves attention and reduces impulsivity in schizophrenia, and might even be protective against later development of the disease:

Regardless of whether nicotine is therapeutic in schizophrenia, smoking certainly isn't. People with the condition die much earlier on average than the rest of the population, and they generally smoke like chimneys. Their health needs to be protected by diverting them to e-cigarettes as soon as possible.

Nicotine might also help memory in early dementia, but there is a long way to go in researching nicotine's therapeutic or even cognitive enhancement potential.

For the moment, it's worth remembering that legal or illegal, you can't protect people from the harms of drugs if they are insufficiently regulated. Government needs to step up and get to grips with this issue.

Monday, 17 December 2012

Concerned parents need to take up arms for the new 21st century War on Drugs

The vital drug policy debate that is increasingly occurring worldwide is encountering some difficult obstacles. The passage up the lower slopes of the political mountain is getting increasingly smoother, as can be seen in the substance of the Home Affairs Select Committee report that was published last Monday. But when the arguments reach the political pinnacle, they are met with the usual intransigence and a gentle nudge off the nearest cliff-edge, only to resume their long ascent back to the top table.

Much of the problem faced by the arguments for reform is created by the language used to characterise those arguments. These arguments are sometimes deployed by reformist advocates themselves, and sometimes by the clumsy journalists that report them, but each mention of “ending the war on drugs” or “liberalising the drug laws” creates a narrative in which drugs are winning a war or winning their freedom. In a policy debate that follows this narrative, the figures at the political pinnacle are being asked to admit defeat in a war, failure of their policies and to announce tolerance of the existence of what is widely regarded as a social evil. Even on a good day it is hard to imagine political leaders doing one of these things, never mind all three.

The slogan “end the war on drugs” has to go. Like the “Robin Hood tax”, it may have been good as a rallying cry to raise the profile of the cause, but it is essential that it gets ditched before the final push.

In my speech to last year's Liberal Democrat conference proposing the Liberal Democrat's new policy I suggested we adopt new weapons for a new, 21st century war on drugs. The 21st century war should continue to be a war on drugs, but the goal of eradication of drugs from society was always unattainable and has to evolve into a different, and potentially achievable goal.

The 20th century war was ugly and imprecise, effectively carpet bombing large areas of our cities with myriad harms. It was a war in which collateral damage appeared to be an explicit goal rather than an accident best avoided. In a war on drugs, why were humans going to jail? The 21st century war on drugs should instead take inspiration from ancient history and adopt a distinctly Roman style of capture and enslavement. It should be defined by the goal that drugs can be be our slaves but never our masters.

And that goes for all drugs. When a hard-working citizen returns from work on a Friday night and demands a soothing head massage from their servant drug, who are we to dictate whether that drug be a glass of red wine or a cannabis joint. The state has a role in educating on how a drug best be handled, and if a drug looks like it has ambitions to become a citizen's master, the state and citizen need to be able to work together to put that drug back in its place, or to help the user dismiss the drug if the situation becomes too perilous.

There are far too many citizens around the world who's lives are currently ruled by drugs. Where heroin or crack is master, many are compelled to steal, deal or prostitute themselves to unsavoury men on dark streets. Where cannabis becomes master, all too often the instructions coming from the drug are mutating into the bizarre and isolating orders from the voices of psychosis. There are many drugs whose power over their users becomes so great that the other things of importance in their lives are neglected. Partners, children, jobs, cherished pastimes, all falling by the wayside because of the unchecked power of illegal and unregulated psychoactive drugs.

And it is not just users that fall victim to the power that drugs hold. When greed and ambition are combined with the presence of drugs and a dearth of other opportunity for achievement another kind of victim is frequently created. With the heady combination of greed and drugs as master, those who get involved in the drugs trade have been drawn into a life fraught with danger of incarceration or extermination at the hands of their peers.

So how do we achieve this drug war victory in which drugs are our servants and never our masters?

Well, I'm going to set an example by shifting abruptly from metaphor into clear description of what policies and procedures a post-reform UK could employ. Despite the pro-reform debate in the media being dominated by extremely sensible advocates such as Tom Lloyd - the former chief constable for Cambridgeshire - and representatives of the charities Release and Transform, the media still throws up daft speculation. Will class A drugs will be available at corner shops? Will legalisation lead to widespread cannabis experimentation and increased incidence of psychosis resulting from that?

The positions of these prominent reformers and myself have come from careful consideration of evidence and the utilisation of logic and reason. All combined with a determination to reduce the harms that drugs and the laws governing their use cause to individuals and society.

For me the evidence and logic points to the immediate adoption of the Portuguese system in full. Their addicts are getting treated, heroin addiction is much less prevalent and their jails are less crowded. Their investment in drug services combined with their decision to decriminalise possession of drugs for personal use have been a resounding success for drug users and their families. Rather than tolerating drug use, anyone found in possession of drugs is referred to a Commission for the Dissuasion of Drug Addiction. The message being sent is not that drug use is ok, but that the government cares and wants to help users find health and happiness.

I am in no doubt however that Portuguese services could be better still. In Switzerland and a growing number of European countries that have followed their lead, heroin assisted recovery clinics are being utilised as means of engaging addicts with treatment services. Heroin is far more effective than methadone at reducing street drug use, drug-related criminality and retaining users in treatment so that their other social, economic and medical problems can be addressed. Heroin clinics, where the drug is provided for use inside secure premises under medical supervision, can reach those chaotic individuals for whom methadone is at best a stop-gap between hits of the real thing and at worst just another deeply unpleasant prescription inflicted upon them by the state.

Heroin assisted recovery clinics provided with much broader eligibility criteria than at present could really help users and their families to find hope that they need not live a life of criminality and squalor. But such a policy can also reach those victims of greed that decriminalisation does not. The more heroin addicts are attracted to new clinics and other means of rehabilitation, the more the requirement for criminal suppliers to fill that gap in the market is undermined. Only by effectively treating as many existing addicts as possible can we have a fighting chance at removing the dealers from communities and preventing them recruiting another generation into the same grim lifestyle.

Please excuse the return to metaphor but pharmaceutical heroin really is the slave that nurses the stricken addict and protects him or her against the domineering master that is the heroin available outside the clinic's walls.

As effective as decriminalisation was in Portugal, it can not be a policy endpoint in itself. Why would you take away the intended deterrent of criminalisation of possession but still leave the manufacture and supply in the hands of criminals with all the negative consequences that entails? Without consideration of the international context any rational examination of Portugal's decriminalisation policy would find it to be utterly bizarre.

Legal regulation of drugs was not considered as a policy solution in Portugal only because they were a signatory to the UN drug conventions. Yet in recent weeks Uruguay and the US states of Washington and Colorado have announced their intention to introduce regulated supply of cannabis for recreational use in direct defiance of these well-meaning, but utterly misguided documents. If Uruguay can do it they why should the UK not be a pioneer, perhaps devising a middle way between Uruguay's state monopoly and the American free market model, a carefully designed model that will have the best chance at public and international acceptance.

The British public are rightly concerned about the potential for cannabis to compromise the mental health of young people. Having lived with the traumatic presence of a psychotic family member in my own life for the last 15 years, I have long been driven by a desire to prevent other families having to navigate the distressing events and uncertainty my family has been forced to endure.

Cannabis legalisation does not have to be a blind leap of faith into an unknown, chaotic free market. Why would we take cannabis out of the hands of immoral criminal profiteers and place it into the hands of immoral corporate profiteers? Doing so would likely imperil the mental health of the population and we should resist such a model as fervently as we should rail against the status quo.

Instead we should seek to design a model for which capture and enslavement would be an eminently suitable metaphor.

If cannabis is to be sold in shops it should be sold by trained professionals who have been educated thoroughly on the various risks and harms that the drug presents. Those professionals must then be responsible for educating customers in turn. Of vital importance is that every cannabis user should be able to identify the early warning signs of psychosis in themselves or in their peers. Indeed without that goal, cannabis legalisation loses a lot of its appeal to me. Given the prevalence of psychosis in society, the early age at which it can attack, and its devastating long-term impact, you'd think that teenagers should be being taught about psychosis anyway. To legalise a drug whose users experience psychosis at twice the rate of the general population and not to provide that education as a condition of purchase would be negligence of the highest order.

When a customer does experience signs of psychosis, it is imperative that we learn from that in order to adjust our advice to the rest of the cannabis-using population, and it is with that in mind that I propose an online, structured, consumer support community. When a user takes a particular strain or preparation, they should be strongly encouraged to review their experience with that form of the drug. Much as many online vendors now tailor recommendations to their customers with the phrase “users who purchased x also purchased y”, the cannabis-using community could be given recommendations based upon their enjoyment of particular strains and preparations of cannabis. Such an online space would hopefully be welcomed by users as a means of identifying the strains that they would most enjoy, but would also be very useful in diverting users away from strains that might compromise their sanity or other aspects of their health. The possibility of consumers agreeing to the combination of this data anonymously with medical records would also rapidly advance our understanding of the relationship between cannabis and health, both positive and negative, and help us modify the regulatory model to better serve the interests of users and the community in general.

Cannabis is a dangerous drug. The families of those who have developed psychosis associated with its use are very right to be vocal in highlighting those dangers. What needs to be recognised however is that their child's illness was born in an unregulated illegal market. These families have a choice. They can fight to preserve the prohibition system that so tragically failed their children, or they can fight to create a regulated system in which children are better protected. With adults being served by legal vendors, it will be so much harder for dealers to maintain a worthwhile income by dealing to children. Rather than the paltry fines we see for alcohol resale to minors, concerned parents can lobby for severe punishment for those who deal to under 18s. They can also join me in lobbying for the provision of much improved mental health and drugs education in schools. The skunk they so deplore is a product of the black market profit motive. To fight to preserve the illegality of the drug is to promote skunk's dangerously dominant position in the market and the livelihoods of the hated individuals who corrupted your child's mind.

Reform of drug laws is only going to go one way. Gone are the days in which we can aspire to arrest and charge everyone using cannabis. We can't afford the expense, and society would not tolerate the persecution of children being a priority. We also know from international experience that greater enforcement does not lead to lower use. The deterrent effect is a myth (at least at the population level). Concerned parents have to instead consider how their children would be better protected and start participating in the debate in order to promote their family's interests. The regulatory model that is coming should not be shaped by the concerns of bureaucrats and drug users alone. Concerned parents and families who have fallen victim to prohibition's failings have to be the loudest voices at the negotiation table if the harms of cannabis are going to be effectively restricted.

One issue parents should engage with is the problems that might arise if there were companies who would profit from the artificial promotion of cannabis, or particular strains. It might therefore be wise for commercial interests to be excluded from the market altogether. The best way to prevent advertising and marketing encouraging consumers to make decisions against their interests and those of society is to as far as possible ensure that nobody's wealth would be dependent upon continued use of the drug or of particular forms of the drug.

It is quite possible a state monopoly is the only model that can demonstrate to the voters that legalisation is a process we are embarking upon with appropriate care, with the highest regard for the health and happiness of the nation.

If this proposal works in reducing the harms people experience as a result of using cannabis, and the many harms associated with the illegal trade, then it would be highly responsible to extend the model to other drugs. One by one we can capture and enslave drugs into service of health and happiness, releasing people from the yoke of addiction and the impact of the crime and ignorance that goes hand in hand with prohibition and the illegal market.

While Nick Clegg should be lauded for being the first sitting government minister to demand a change in our approach to drugs, David Cameron is also right to reject a Royal Commission. For too many people 2015 will be years too late. There are teenagers (some even younger) smoking cannabis regularly in all of the UK's cities and towns, blissfully ignorant of the horrible, desperate, psychotic life they are risking. There are young addicts all around the country prostituting themselves to fund their next fix. Putting themselves in harms way because politicians don't have the courage to accept that the best treatment for them and their community is to provide them with a clean preparation of their drug of choice. And the lottery of criminalisation keeps making its daily draw with no-one asking why young, black, and poor seem to be the balls that keep dropping out of the machine, while middle-class, white, cocaine-user, banker and politician keep spinning around and around without a care.

Drug policy reform is not about liberating drugs. It's about liberating people from ignorance, persecution and the drugs that have power over them. Can we please finally declare a war on drugs so that we can capture and enslave them and put them to work easing our pains and helping us smile. Without a proper war on drugs with sensible, realistic goals, too many people will be left to fight and lose their own personal battles without the knowledge, help - and in some cases drugs - that they need to triumph.

It doesn't take courage to call for a two year examination of the available evidence. It does take courage to stride proudly in front of public opinion, call for the adoption of policies that we know have worked elsewhere, and present an innovative model that can finally start to bring dangerous drugs under effective control.

I implore any politician reading this to find that courage.

Wednesday, 12 December 2012

Cannabis should be legal BECAUSE it is harmful

Some people have been pointing to this article by Patrick Cockburn as something that should be read before uncritically accepting the HASC recommendations.

This is the letter I wrote in response to a previous article by Patrick and another by John Rentoul that were published in the IoS last year. I thought it would be worth publishing it again. An edited version was published the week after in the IoS but I can't find it online. I'm very happy the Independent has printed an editorial this week that has called for decriminalisation of drugs despite Patrick Cockburn's articles on the subject. Please understand that I do not criticise Patrick Cockburn in any way and only have sympathy for what he and his family have had to endure.

Dear Editor,

(in reply to the articles of John Rentoul and Patrick Cockburn of the
5th of June 2011)

I last had a letter published in the Independent on Sunday on the 15th
of September 2002. It was a desperate plea for increased education on
mental health issues informed by my deeply distressing experience of
my brother's worsening psychosis. Within that letter I said "We don't
need it to be easier to lock up the mentally ill. We need a society in
which everyone knows how to look after their mental health and can
look out for the health of others." Some 9 years later, and with a
brother sadly still severely limited by his condition, I am now a
passionate campaigner for the strict control and regulation of a legal
cannabis market. I have taken this position because I recognise the
potential within a strictly regulated legal market for that education
on mental illness to be delivered directly to people who have around a
doubled risk of developing schizophrenia. If cannabis was sold from
pharmacists and there was a requirement to undergo education on the
early warning signs of psychosis before people are permitted to use,
then I do hope that John and Patrick can recognise that "legalising"
cannabis can present a marvellous opportunity to intervene early in
psychosis and reduce its impact upon young lives, families and
society. Permitting use by adults should also reduce the viability of
criminal enterprises that deal to children, and increase the ability
of the police to rightly target such enterprises. Prohibition did not
stop Henry Cockburn using cannabis from the age of 14. I desperately hope that
controlling and regulating the market, alongside improved education in
schools, can reduce the level of use in the next generation and reduce
the incidence and severity of the terrible condition that Patrick and
I have had the misfortune to witness first hand.


Ewan Hoyle.