Archive for the ‘Drugs and drugs policy’ Category

Review of ‘High Society’ at the Wellcome Collection – guest post

Thursday, March 17th, 2011

Unfortunately this exhibition has now closed, but this review by Dr Lisa Conlan is still well worth reading.  It was originally featured in the London Division March 2011 newsletter.  Photo credit: Wellcome Collection

‘Every society is a high society’ is the tagline of this topical and playful exhibition. ‘High Society’ challenges the status quo that we live in an era of unprecedented levels of drug addiction, that it is a very modern disease. With billions spent yearly on the ‘war against drugs’ and UN estimates putting the yearly turnover of the illicit drugs trade at $320 billion (£200bn), it’s easy to see where this idea comes from. In fact, as this exhibition sets out to demonstrate, addiction is nothing new and psychoactive experimentation, rather than a minority activity, is something of a universal experience. Using historical relics, paintings and commissioned installations, ‘High Society’ charts humanity’s long and intimate relationship with mind-altering substances, licit and illicit, be it caffeine, alcohol, kava root, opium, cocaine eye drops. You name it, this exhibition has got it.

The first part takes a brief but broadly historical look at drug use and trade through the ages, focusing on the important role opium trade played in the 19th century in the development of the British Empire. As tea increased in price and the British ran out of silver to exchange for it, the East India Trading Company sanctioned the mass manufacture of opium in India to trade for it; actively establishing, promoting and fostering opium addiction in China. 

A good part of the exhibition is given to an anthropological overview of drugs, from ritual kava ceremonies in Polynesia to Native American peyote. Colourful US Prohibition-era posters hint at the current debate on legalisation but sadly, this theme is explored no further. There are featured original manuscripts including Samuel Taylor Coleridge’s Kubla Khan and Thomas de Quincey’s Confessions of an English Opium-Eater. Paintings and photographs are used to good effect, in particular, Keith Coventry’s haunting photographs of gaunt crack addicts. Fun installation pieces recreated the dizzying experience of being high, my favourite being Rodney Graham’s comical acid-fuelled bicycle ride to a Pink Floyd soundtrack. Some interesting film and video excerpts were featured, including Jonathan Miller’s wonderful and enchanting BBC version of Alice in Wonderland, 1966, shot as if in the haze of a drug-fuelled dream (or perhaps a nightmare).

My main criticism of the exhibition was the lack of decent explanatory material. For example, there was brilliant video footage of the landmark late 1970s experiment by Bruce Alexander, known as ‘Rat Park’, but little, in fact, almost no notes to aid the viewer to make sense of it. This is a shame because it was a landmark addiction experiment, which challenged the orthodox theory of addiction, still very current in addiction research and treatment today, that dependency is a property of the drug itself. Alexander, who worked with addicts for years as a clinician, thought dependency was more about social and environmental factors than the intrinsic power of the drug itself.

Briefly, for anyone who’s interested, the experiment consisted of caged rats versus rats in a park called ‘Rat Park’. Rat Park was a large plywood construction designed so rats could roam free with ample space for social interaction and play, food, and nests for raising young. Both sets had the choice between morphine-laced water or tap water. Despite many attempts and variations on the experiment, Alexander could not make addicts of the rat park rats. The caged rats preferentially took the morphine solution and became dependent, while the rats in Rat Park overwhelmingly preferred water. In one variation, Alexander exploited the fact that rats are very partial to sweet things by adding sugar to the morphine solution (morphine has a bitter taste). As before, the caged rats preferentially drank morphine but, in general, the rat park rats snubbed it for water. It was only when naloxone was added to the water that the rat park residents started drinking the sweet morphine water. In another striking variation, Alexander transferred addicted caged rats into the Rat Park to see what would happen. The transferred rats mostly took up tap water instead of morphine, suffering mild withdrawals only. Alexander concluded that in optimal social conditions, the rats did not want anything that would interfere with their normal social interaction and attachment. Alexander’s theory was that it was not an inherent property of the drug that led to dependency but social and environmental deprivation and distress. Alexander could not get his work published in Nature or Science and it was later published in the minor journal, Pharmacology, Biochemistry and Behavior, and failed to have any impact. It’s interesting to note that this experiment was replicated on a human scale (this wasn’t in the exhibition by the way) when the Vietnam veterans returned to the USA. Thousands had severe heroin dependency but back in their home environments most just stopped using when they returned home, also suffering only mild withdrawals.

So, despite the general lack of explanatory text, High Society was a stimulating, fun and thought-provoking exhibition.

High Society website

High society: Mind altering drugs in history and culture by Mike Jay

Dr Lisa Conlan, General Adult psychiatrist, currently in an Addiction Post

Letter to forth.ie – ‘Losing our minds on drugs’

Sunday, April 25th, 2010

forthfp

Here’s a letter I’ve just sent to Forth.ie:

Dear Sir,

I read with interested your article ‘Losing our minds on drugs’ which discussed the recent furore surrounding the now controlled recreational substance mephedrone.  Your article correctly identified that much of the reporting concerning mephedrone’s harms was inaccurate and that subsequent government policy owed more to moral panic than level-headed analysis.  The rest of the piece bemoans that drug use is not the ‘relatively straightforward issue of civil liberty’ that it should rightfully be and criticizes doctors who would wish for medical expertise to override politics.

Whilst it may be attractive philosophically to consider that drug use is a ‘private behaviour’ and ‘no business of the state’, I would question whether this position is workable in practice.  The legalisation of all drugs that this supposes would have some benefits.  For instance a drastic reduction in crime might be expected.  For users there would be freedom from criminal dealers and purity of product.  However many drugs of abuse have effects on physical health which would presumably be addressed by state run healthcare systems.  Addiction is also a cause of unemployment.  Drug use can hardly be described as a ‘private’ matter if users are supported on benefits and after use care is socialized.

If we can agree that there should be some restrictions on substances of abuse then the question is how this should be settled upon.  The current UK Government approach is muddled.  The Advisory Council for the Misuse of Drugs (AMCD) exists to advise the Home Secretary about drug policy.  Recent form suggests that the Home Secretary is happy to listen so long as the AMCD is saying what he would wish to hear.  Drs Taylor and Carlin had been incorrectly informed that their opinions were of interest and rather than chastised for their ‘demand that medical expertise override politics’ might be forgiven for expressing their dismay at discovering otherwise.  The UK Government appears to have a moral agenda but one which they have wished to present as a having scientific credentials.

Finally, is it reasonable to invoke of the harms of legal drugs in the discussion of illegal ones?  You appear to think not.  It’s certainly simplistic to dismiss the need to control currently illegal drugs on the basis that alcohol is much more hazardous.  But can it be possible to make a true assessment of the harms of illegal drugs without comparison to those which many people currently know and use?   This presumably is an equation into which a user of illegal drugs enters regularly enters.

Yours etc.

Stephen Ginn MD

As seen on forth.ie

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Mephedrone

Sunday, April 4th, 2010

mephedrone-crystal

Last week the British Government made clear its intention to ban the currently legal stimulant 2-methylamino-1-p-tolylpropan-1-one also known as mephedrone.

For anyone who lives in a cave, mephedone is a chemical that has stimulant properties when ingested and has recently become very popular on the club scene as a ‘legal high’.  It’s from the cathinone class of compounds.  This class also includes the active ingredient in khat, a plant whose leaves are chewed with great enthusiasm in Yemen.  It’s not difficult to see why mephedrone has purportedly become so popular (no figures actually exist).  It’s been legal up until now so has been extremely easy to acquire without consorting with grubby drug dealers.  Further it’s cheap and the quality of supply is reasonably reliable, unlike illegal equivalents.

Some things about the mephedrone story are quite novel.  Legal highs, which once had a reputation for poor efficacy are now causing a great deal of interest.  The internet is making the drug much more easily available than it would have been under similar circumstances twenty years ago.  The emergence of China’s economy has meant that there is plenty of capacity for manufacture.

What’s less new is this reminder of quite how much we British like getting off our heads.  The stereotyped response from the media and UK Government also comes as no surprise.  The media have focussed their attention on a number of deaths with which mephedrone has been associated, although no causal link has established.  The Government’s actions in banning the drug appear dictated by tabloid furore and based on moral panic and a wish to seem decisive with an election six weeks away.

The use of psychoactive substances of unknown toxicity being used recreationally is a legitimate focus for government concern.  However the advice to ban this drug was provided by an advisory council (The Advisory Council for the Misuse of Drugs) on which three places remain unfilled and prohibition under these circumstances may not be legal.  The ACMD’s report on mephedrone has not been made available for public scrutiny.

The ACMD’s enfeeblement may matter little to the Home Secretary. He appears not to listen to his advisors anyway.  Another AMCD member yesterday over the affair.  He wrote in his resignation letter:

“We had little or no discussion about how our recommendation to classify this drug would be likely to impact on young people’s behaviour. Our decision was unduly based on media and political pressure”

Unfortunately evidence based drugs policy does not exist in this country.  If it did any deliberation of this new drug would surely have been more considered and we’d be able to admit that mephedrone is a side show compared to the damage done to health by alcohol and cigarettes.  It is also inconsistent to ban mephedrone and not khat, which was omitted from the ban presumably to avoid pissing off ethnic minorities.

It’s true that based on its chemical class mephedrone use is unlikely to be without hazard.  However banning it will throw up another set of issues from fatalities owing to adulterated supply to deadly turf wars.  Moderate voices, including the former head of the ACMD, suggest that the most appropriate way of dealing with drugs of unknown toxicity is a ‘class D’ whereby a drug is “quarantined” and sale of it to anyone under 18 is prohibited.  Thereby allowing time for a thorough examination of harms.

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Further reading:

Drugscope article: Mephedrone – the future of drug dealing?

Druglink blog: Media muddle over mephedrone

Smart Drugs

Wednesday, March 17th, 2010

super-smart-drugs

In a debate that’s only going to get more interesting, there were recently calls for universities to consider dope testing to detect the use of ‘smart drugs’ amongst their students.  These drugs, also known as nootropics (an inelegant name; from the Greek roots noo-, mind and -tropo, turn, change) or cognitive enhancers are becoming increasingly widely used.   If the high estimates of use are to be believed then the debate about and reporting of their use has been remarkably restrained, especially when compared to the perpetual state of conflict over cannabis classification and the coverage given to mephedrone.

Cognition enhancement by pharmaceutical means is not actually a new phenomenon; caffeine is in fact a cognitive enhancer with which we are all already well acquainted.   Modern cognitive enhancers were not originally developed with the intention of improving concentration in healthy people.  Methyphenidate (also known as Ritalin) was originally licensed for attention deficit hyperactivity disorder and modafinil for narcolepsy.  Other drugs such as donepezil are licenced for use with people suffering from dementia.  Most of the drugs effect the chemical pathways of neurotransmitters dopamine and noradrenaline in the brain.

The main effects of cognitive enhancement drugs are said to be to improved cognition, memory, intelligence, motivation, attention, and concentration.  Research has found that they improve the performance of healthy people on tests of cognitive function. They are easy to purchase over the internet and appear to display minimal adverse effects.  Most people agree that there are large groups of people for whom prescription of cognitive enhancement medication is extremely appropriate, such as those suffering from neuropsychiatric disorders.  It is their use in the healthy which is likely to become increasingly controversial.

There are of course plenty of drugs that healthy people like to take, but most of the others have been made illegal.  This prohibition been justified on basis of harm to the individual and society, but fear of the consequences of unrestricted hedonism of the proles also plays its part.  This latter issue may tell us why drugs that encourage studious academic application are not causing much of a stir.  Complacency may be misplaced as methylphenidate is a stimulant and does have addictive potential; anyone who works more efficiently has additional time for carousing.

Cognitive enhancers would seem unsuitable to join the ranks of banned substances and are likely to be here to stay.  The current economic situation may necessitate many of us to work into our 70s, and cognitive enhancement may allow older employees to remain more competitive.  They have already thought to have been used to improve the performance of soldiers in Iraq, and the UK Ministry of defence may have acquired a supply.  Baby-Boomer dementia may lead to high demand and pharmaceutical companies are unlikely to forsake a major market for their products.  The appetite for regulation does not appear to be particularly strong.  The Advisory Council for the Misuse of Drugs’s 2008-2009 report (pgs 2 and 32) only mentions that the UK Government has “asked for advice”.

Some people see no problem with using pharmaceuticals to improve on our abilities, whilst others feel that to use substances to gain advantage is unfair.  Anyone who seeks to restrict cognitive enhancement drugs on this basis must answer the charge that unfair advantage is already ubiquitous and generally tolerated in our education system.  Cognitive enhancers could in fact actually correct rather than exacerbate educational inequality.  The argument that students will feel obliged to take cognitive enhancers should all their colleagues be doing so is a stronger one, but restricting the autonomy of all people for fear that it may influence the actions of some is philosophically fraught.  Drug testing students before exams is unlikely to be practical, especially since advantage could be gained by students using cognitive enhancers using revision periods.

Maybe the most pressing concern is that many users are buying their medication off the internet.  This is unregulated and possible drug interactions and side effects go unsupervised.    There are also concerns about the effects of long term use of cognitive enhancers and also of their effects in the young on the developing brain.  One option to introduce some supervision and expert advice would be for medical professionals to more routinely prescribe these medications, although this is unlikely to be something that publically funded health services could underwrite .  Many doctors may feel uneasy about administering medication to the healthy, but it may not be long before we begin to recognise and treat “poor concentration”.

See also:

Cakic V. Smart drugs for cognitive enhancement: ethical and pragmatic considerations in the era of cosmetic neurology. J Med Ethics 2009;35:611–615

Smart drugs: lecture to the Royal Institution of Great Britain Prof Barbara Sahakian 22 February 2010

Turbocharging the Brain–Pills to Make You Smarter? Scientific American October 2009

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“A muddled moral and political agenda”

Sunday, November 1st, 2009

drugs_graph_416

Having been sacked from his position as the chief UK government drugs advisor Professor David Nutt may today be reflecting on the precarious position of anyone who seeks to advise politicians on controversial matters.

For it seems that whilst such an advisory position would appear to call for candour as a job requirement, in reality an expert who expresses an opinion out of step with the thinking of his or her political masters will find this leads to chastisement and the possibility of dismissal.  Nutt irked Home Secretary Alan Johnson by penning an article which criticized the UK’s drug classification system and in particular the way in which the previous Home Secretary Jacqui Smith ignored learned advice against reclassifying cannabis from class C to B.  He also suggested that if the argument against the use of drugs by UK subjects is driven by the drug’s perceived harms, then it would be appropriate to compare these harms to the risks run by users of currently legal drugs as well as other harmful activities.

As far as the Alan Johnson is concerned, this is so say the unsayable.  In his letter requesting Professor Nutt’s resignation Johnson wrote “It is important that I can be confident that advice I receive from the AMCD (Advisory Council for the Misuse of Drugs) will be about matters of evidence.  Your recent comments have gone beyond such evidence and have been lobbying for a change in government policy”.

When it comes to drugs, Mr Johnson is not the only person who has admired scientific advice only insofar as it agrees with current policy.  As well as ignoring the AMCD’s advice regarding cannabis, Jacqui Smith also vetoed their recommendation that ecstasy be downgraded from a class A drug, a conclusion that involved the AMCD  reviewing four thousand scientific papers over a twelve months period.  Internationally the situation is hardly better.  In 1995 the World Health Organisation conducted a thorough survey on global cocaine use.  Although eventually leaked, the full report was never officially published as the US representative to the WHO threatened to withdraw funding unless the organisation dissociated itself from the conclusions of the study and cancelled its publication.  The report had suggested that use of cocaine did not necessarily lead inexorably toward either individual or societal collapse.

The debate on drug legalization appears, as Professor Nutt has found, to be almost uniquely charged.  The reasons for this are complex but perhaps are rooted in drug use’s consequences being, at worst, easy fodder for any right wing commentator: people enjoying themselves, youth running amok and slothful hippies; successive governments have run scared from sections of the popular press that purport to represent the attitudes of the public.  It is reasonable to be very wary of drugs as some, but not all, of them have the potential to do great harm but our current debate is distorted and muddled and the focus on illegal drugs in isolation blinds to the damage currently visited by the excess use of alcohol.

Despite the positioning of politicians, Dr Nutt’s resignation shows us that UK drug policy is clearly driven not by sober reflection of evidence and what this tells us about harm, but rather lip service is shown to scientific opinion which then partially conceals an unacknowledged moral and political agenda.

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Latest news

Ministers face rebellion over drug Tsar’s sacking Guardian 1 November 2009

Drugs: Prejudice and political weakness have rejected scientific facts Observer 1 November 2009

Today programme interview with David Nutt 31 October 2009

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This post is also published on Forth :: forward thinking from Ireland

Nutt decision shows the immaturity of the marijuana debate

David Nutt resigns

Friday, October 30th, 2009

nutt

Chief government drug advisor Professor David Nutt, has resigned from his position today following an publication in which he discussed the relative harms of currently illegal substances compared to those which are widely available such as alcohol.  Seems sensible, but the distinctly illiberal Alan Johnson MP seems unprepared to enter into nuanced debate.

This is not the first time Professor Nutt has landed himself  in trouble with a Home Secretary;  he was severely reprimanded by Jacqui Smith in March 2009 following publishing an article which compared the dangers of using ecstasy with those of horse riding.  But clearly he’s now used up all his nine lives.

Paper trail:

The publication in question:
Estimating drug harms: A risky business

Digest in Guardian 29 October 2009
The cannabis conundrum

Guardian 30 October 2009
Government drug advisor David Nutt sacked

The Sun 29 October 2009
Drug advisor on wacky baccy?

The Guardian 30 October 2009 Robin Murray
A clear danger from cannabis

Guardian 30 October 2009
Chief drug advisor David Nutt sacked over cannabis stance

Guardian 31 October 2009
Drugs policy: shooting up the messenger – Editorial

Guardian 31 October 2009
Professor Nutt’s sacking shows how toxic the drugs debate has become

BBC Mark Easton Blog
Nutt gets the sack – includes Alan Johnson’s letter and David Nutt’s reply

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“Let’s fix Britain’s drinking problem”

Sunday, September 13th, 2009

guardian_logo

In a major development for Frontier Psychiatrists everywhere I wrote this article which was published on the Guardian newspaper Comment is Free website on Friday 11 September.  Not that it really matters, but up until this point this blog was semi-anonymous, and this has comprehensively blown my cover…

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The former president of Brazil, Fernando Henrique Cardoso, said last week that the war on drugs had failed and that there was a need for a new global strategy concerning illegal drug use with a shift toward decriminalisation. Although progress is glacial, his sentiments do appear to reflect a growing change in attitudes, the most concrete example of which has been Portugal’s 2001 decriminalisation of all drugs, giving it the most relaxed drug laws in the European Union.

Portugal’s move has not led to nightmare scenarios of out-of-control drug use or “drug tourism” and has allowed Portuguese healthcare to more effectively offer treatment programmes to its citizens. Should Portugal’s move become a trend, a future UK government may be tempted to follow suit. However, before taking steps that may increase the ease with which currently illegal substances may be possessed and consumed, the will must be found to tackle our crisis of excess alcohol use, a drug that is already legal and widely available.

Many people use alcohol moderately and sensibly. However, millions of us do not. The harm alcohol causes is so broad that it is hard to adequately summarise it. The problems with health and public disorder are well documented, but more invisible is the toll it takes on relationships and mental health. It affects young and old; today an article in the Lancet identifies alcohol as a major factor in teenage mortality.

Despite this, the government’s attitude towards alcohol use has been predominantly soft-touch and we have seen a relaxation of licensing laws as well as local councils that appear to think nothing of allowing so many bars in certain high streets that they become a virtual no-go area to all but the most intoxicated. The large commercial concerns that produce and sell alcohol have been allowed to go about their business largely unchecked and alcohol use is widely encouraged by virtually unrestricted advertising and pricing practice. Also unhelpful is the socially corrosive veneration of alcohol-related culture that is displayed by some influential institutions, including student unions and some radio stations, whose shows regularly encourage people to relate stories of alcoholic excess.

Decisive action is needed towards curbing alcohol misuse. A report this week from the BMA calls for alcohol advertising to be banned and for the trend of music festival tie-ins to be similarly prohibited. A reduction in the density of licensed premises in town centres is also recommended.

Alcohol pricing must more accurately reflect its cost to society with the introduction of minimum prices for alcoholic drinks. More broadly, public opinion makers need to become aware of the effects of the attitudes they propagate and on this issue seek to lead rather than follow. There is cause to be optimistic: the realignment of attitudes toward drink-driving and smoking in public places shows that major shifts in policy and public perceptions on drug-related issues are possible and can take place relatively quickly.

Follow-ups in CiF

The case for legalising all drugs is unanswerable 13 September 2009

It’s time for a U-turn on drugs 14 September 2009 about this report Zero Base Policy

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Addendum 16 September 2009

New Scientist 15 September 2009 Blueprint for a better world: legalise drugs

Drugs – no free lunch debate

Wednesday, July 15th, 2009

Psychiatric drug critic Joanna Moncrieff and biomedical model champion Dr Trevor Turner were talking on the Today programme this morning.  The bone of contention is Moncrieff’s assertion, that we should not consider psychiatric drugs to be correcting an inherent ‘chemical imbalance’  and thus correcting a physiological abnormality, but rather to be drugs that alter brain states sometimes in a useful way.  I quite like this approach, it seems more humble and moves away from a ‘disease and correction’ model toward a more pragmatic symptom based model, which may be more compatible with non-pharmaceutical intervention.

Today discussion – 15 July 2009

Moncrieff’s paper – How do psychiatric drugs work?

Co-incidentally, I’ve volunteered to oppose the motion ‘this house believes that our lunch should continue to be funded by the pharmaceutical industry’ at a meeting today.  The ‘no free lunch’ debate is an ongoing one arising from concerns that pharma’s influence on doctors leads to a medical model biased towards ever increasing prescribing, a situation which is better for the pharmaceutical companies than for our patients or wider society.

Here is it, as ever I’d like to know what you think, unfortunately unless you comment in the next 30 minutes I’ll be unable to change the text!

I wish to oppose the motion “this house believes that our lunch should continue to be funded by the pharmaceutical industry”.  This is important for both our independence as doctors and is in the interests of our patients.  I will outline here why we should be wary of the pharmaceutical industry and why we should not accept their hospitality;

First a bit of history.  Before the 1930s doctors were pretty useless.  We had insulin, morphine and had worked out the benefits of conducting operations in sterile conditions, but that was about it.  Then miraculously an era of advancement between 1930-1970 produced an impressive array of medical cures such as antibiotics, transplants, ITUs, dialysis and during this time pharmaceutical companies grew big by producing and promoting innovative medicines for major diseases.

However of recent years it has become ever more difficult and expensive for these companies to repeat such successes and the number of genuinely innovative new products being released by them has significantly reduced.  I would argue that the continuing benefits of prior triumphs have led us to view pharmaceutical companies in the positive light of their past achievements, and we do not sufficiently scrutinize their current practice.

Today’s situation is that faced with maintaining their profits without the support of truly innovative products, pharmaceutical companies have engaged in refashioning and repackaging old products as ‘innovations’ and, worse, identifying and promoting new diseases for their medicines.  Many of the truly innovative treatments that have emerged in recent years have come from the funding of public bodies, whilst pharmaceutical firms have concentrated on ‘me-too’ drugs which aim simply to gain footholds in established and lucrative markets.

Psychiatry is particularly vulnerable to drug company tactics.  Our sketchily defined diseases provide opportunities for increasing product sales as they allow scope for expanding definitions of sickness, for instance depression, social phobia, female sexual dysfunction, to include more and more areas of social and personal difficulty not previously within the medical realm and thereby sell more medication.  Overall this has been  a very successful tactic and antidepressant prescribing increased 173% from 1991 to 2001.  The UK’s overall drug spending has increased from 3.9% GDP in 1960 to 7.7% GDP in 2002.

There are other concerns too.  The industry’s heavy involvement in the organisation of research into psychiatric drugs and the dissemination of research findings raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. They also seek to gain advantage by political lobbying and funding drug-friendly patient support groups.  There has been disquiet about the burying of negative trials and over the exaggeration of drug benefits as newer expensive treatments such as SSRIs and atypical antipsychotics have not proved more effective than older and cheaper alternatives.

Pharmaceutical companies have thus sold us a reductionist biomedical model of the world.  They haven’t done this on their own of course, as it suits the purposes of many to live in a world where there are simple problems requiring simple solutions, but they have done their best to make sure that their voice is heard above any of those that might provide an alternate, non pharmaceutical vision.  For human beings can survive without endless drugs to cure every possible ill, but the companies that prescribe them cannot.  Pharmaceutical companies are primarily commercial concerns, and their major motivation is maximizing their profits.
But does this knowledge necessarily stop us accepting a free lunch from the dark side?  After all it saves us from buying our own thus allowing us to conserve funds in these uncertain times.  Can we not use our contact with pharmaceutical company representatives to evaluate what they tell us and learn about their products?

I argue no and for one simple reason: because we are weak.

Ask yourself this question: why would a commercial company, to whom profits are key, spend money on buying us lunch if they felt it would make no difference to our behaviour?  The answer is that they wouldn’t.  They know that by their engagement with us they can persuade us to use their products despite any other reservations we might previously have had.  They know that they can influence us to choose the treatment that is best for them, and not necessarily best for the patients we seek to treat.

You don’t need to believe me on this one.  Believe the authors of an article in the JAMA, who found that meetings with pharmaceutical representatives were associated with changes in prescribing practice.  And the next time you use your sponsored pen, consider an article in the Am J Bioethics, which concluded that ‘considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize’.

The true situation is that pharmaceutical companies realize that in order for their products to find a market, they must first influence doctors to prescribe them and they spend a lot of money ensuring this takes place.  From early in our careers they win our favour by providing small gifts, and by taking part in medical education seek to inculcate us with their world view.

We should realise our vulnerabilities and not tempt ourselves so.  I’m not saying that drugs have no place in modern medical health care.  What I am saying is that as doctors we have but one duty, and that is toward improving the health of our patients; any action we may take to place ourselves at the risk of being influenced by another competing agenda is unwise and should be avoided.

For these reasons I commend you to join with me and oppose this motion.  Thank you.

Further reading:

Jackie Law Big Pharma – a comprehensive guide to this subject

Extract from Richard Bentall’s book Doctoring the Mind

Ben Goldacre on Medicalisation from his book Bad Science

The myth of the chemical cure Joanna Moncrieff BBC Health 15 July 2009
The myth of the chemical cure book on Amazon

In the news – update

Tuesday, May 12th, 2009

coloured drugs

On April 7 2009 I posted about a report by the BBC

The Today Programme reported today that care home children whose behaviour during the 1970s/80s was controlled using large doses  of medication have subsequently given birth to children with birth defects.   The drugs in question included Haloperidol, Droleptan and Depixol.  The BBC have Professor Jeffrey Aronson, professor of clinical pharmacology at Oxford University who says that high doses of such drugs can cause genetic damage.  Presumably he’s suggesting that the drugs cause damage to unfertilized eggs – rather than being teratogenic.  These drugs can currently be given to women of child bearing age.  It’s obviously concerning that large doses of sedatives should be given to anyone without a mental health disorder (or even with…) but if they’re right (nb: it doesn’t sound like a very rigerous report and there could be other causes for what they’re suggesting has happened) this would have wide ranging implications.

I contacted Professor Aronson and he was kind enough to reply

At the moment a possible association between psychotropic drug administration and later birth defects (transgenerational transmission of an epigenetic defect) is hypothetical but worthy of further study.

Transgenerational epigenetic effects have been demonstrated in animals and there is some evidence that they may occur in humans. Diethylstilbestrol was used from the 1940s to the 1970s to prevent spontaneous miscarriages. It was subsequently discovered that the daughters of women who had been given it developed vaginal adenocarcinomas. That was a direct teratogenic effect, albeit an unusual one because of the time it took after birth to occur. However, there is now evidence of a transgenerational epigenetic effect as well–the children of those daughters have abnormalities that include hypospadias in boys [1], menstrual irregularities and possibly infertility in girls [2], esophageal atresia/tracheoesophageal fistulae [3], and possibly ovarian cancers [4]. The data are not conclusive, but they are suggestive. Children of those who were affected by thalidomide may also have an increased incidence of limb deformities [5].

This means that theoretically a genotoxic effect could cause epigenetic birth defects down the line, even though the child was not exposed in utero. Cytogenetic abnormalities have been shown in the blood cells of patients exposed to antipsychotic drugs and benzodiazepines for more than 1 month [6]. I know of no evidence about oocytes.

This combination of observations, taken with the story that has just been reported, suggests that the possibility of a transgenerational epigenetic effect of psychotropic drugs should be investigated. It does not, however, prove the association that has been reported, which is based on circumstantial anecdotal evidence and could be subject to confounding by other factors that the affected women shared. 

1. Brouwers et al. Hypospadias: a transgenerational effect of diethylstilbestrol? Hum Reprod 2006;21(3):666-9.
2. Titus-Ernstoff et al. Menstrual and reproductive characteristics of women whose mothers were exposed in utero to diethylstilbestrol (DES). Int J Epidemiol 2006;35(4):862-8.
3. Felix et al. Esophageal atresia and tracheoesophageal fistula in children of women exposed to diethylstilbestrol in utero. Am J Obstet Gynecol 2007; 197(1): 38.e1-5.
4. Titus-Ernstoff et al. Offspring of women exposed in utero to diethylstilbestrol (DES): a preliminary report of benign and malignant pathology in the third generation. Epidemiology 2008;19(2):251-7. 5. Holliday R. The possibility of epigenetic transmission of defects induced by teratogens. Mutat Res 1998; 422(2): 203-5.
6. Bigatti et al. Increased sister chromatid exchange and chromosomal aberration frequencies in psychiatric patients receiving psychopharmacological therapy. Mutat Res 1998;413(2):169-75.
 

Pop stars and drugs

Friday, May 8th, 2009

Elvis Presley visited President Nixon in 1970 to talk to him about, amongst other things, the evils of the drug culture. The picture of them together is one of the most popular in the national archive.

More up to date and I’ve been listening to Lily Allen – pop princess and queen of myspace – ‘s new album ‘It’s not me it’s you’. With her song ‘Everyone’s at it’ she has strayed into social commentary:

I don’t know much but I know this for curtain
And that is the sun poking its head round the curtain
Now please can we leave?
I’d like to go to bed now
It’s not just the sun that is hurting my head now
I’m not trying to say that I’m smelling of roses
But when will we tire of putting shit up our noses
I don’t like staying up, staying up past the sunlight
It’s meant to be fun and it just doesn’t feel right

(Chorus)
Why can’t we all, all just be honest?
Admit to ourselves that everyone’s on it
From grown politicians to young adolescence
Prescribing themselves anti depressants
Now how can we start to tackle the problem?
If you don’t put your hands up and admit that your on it
Now the kids are in danger, they’re all getting hammered
From what I can see everyone’s at it
Everyone’s at it x 3

I get involved but I’m not advocating
got an opinion, yea your well off the slating
so you’ve got a prescription, yea that makes it legal
finding excuses, is well over whelming with people
you go to the doctor and you need pills for sleeping
if you can convince him then I guess that’s not cheating
see you’re daughters depressed, so get her straight on the Prozac
but little do you know that she already takes crack

(Chorus X2)
Why can’t we all, all just be honest?
Admit to ourselves that everyone’s on it
From grown politicians to young adolescence
Prescribing themselves anti depressants
Now how can we start to tackle the problem?
If you don’t put your hands up and admit that you’re on it
Now the kids are in danger, they’re all getting hammered
From what I can see everyone’s at it
Everyone’s at it x 3

At the risk of spoiling her fun, I’ve read through these lyrics a few times and I’m not sure of the point that Allen is trying to make. It’s undoubtedly a tricky subject; witness the scolding that David Nutt recently received from the Home Secretary. With this in mind, perhaps we should congratulate Allen for attempting to tackle such a difficult subject within the confines of a four minute sugary pop coating. But it’s a shame then that her undoubtedly noble intentions have fallen foul for want of a bit of homework.

By my reading Allen’s essential points are threefold: ‘everyone’ does drugs, we’re not honest about this, there is no real distinction between psychoactive drugs that your doctor might prescribe and those you might get from whichever drug dealing, bmx riding youngster happens to be passing by.

I suspect that in Allen’s circles everyone is probably using drugs and staying up all night, which might account for the obvious world weariness of her first verse. However taking the population as a whole – which crucially includes people who have proper jobs, the best evidence (pg 34 onwards) suggests that around a third of all UK 16-59 year old have used illicit drugs; that’s two thirds short of ‘everyone’. Additionally 2.4% of 16-59 used either crack or cocaine powder in the past year, which means that Allen’s scenario whereby someone might go to their doctor for antidepressants whilst also using crack is a scenario which applies to an even smaller number of people.

And I do have sympathy for her assertion that there are double standards concerning drug use. Many prominent people are no more honest about their drug use than they are about the extent of their plastic surgery. PM in waiting David Cameron has refused to discuss his own drug past, saying that he is entitled to a ‘private life’ prior to his entering politics. Home secretary Jacqui Smith has admitted smoking cannabis, as have other prominent politicians.

It is true that your doctor can prescribe drugs of abuse, for instance benzodiazepines, and even heroin under much more restrictive circumstances. We can also prescribe psychoactive drugs such as antidepressants. Some people are keener on the idea of this than others. I would draw a distinction between these two circumstances on the basis of intent. A doctor intends to alleviate distress with his/her prescriptions, helping to reduce sleep problems or improve mood. Recreational drugs are just that – an indulgence.

In other psychopop developments, neo cabaret darlings and Frontier Psychiatrist favourites Bourgeois and Maurice have penned a song called Ritalin. I talked to the Maurice Maurice, one half of this duo, about her inspiration for this song, whose origins are apparently when she was working on an American summer camp and seemingly all the children were prescribed it. Listen to it on Myspace

Finally the Government are also talking about banning currently legal substances. The Guardian reports that ‘Spice’, Salvia divinorum, and ‘herbal ecstasy’ and are under threat. Hoover them up whilst you still can kids…