David Nutt Public Lecture Cfar Auckland2013
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Transcript of David Nutt Public Lecture Cfar Auckland2013
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Welcome: Professor David Nutt, Imperial College London
Drugs without the hot air:
A proper assessment of drug harms and their relative dangers
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David Nutt FMedSci
Edmond J Safra Prof of
Neuropsychopharmacology
Imperial College London
Hon Consultant psychiatrist CNWL
Chair Independent Scientific Committee on Drugs (ISCD)
drugscience.org.uk
Drugs without the hot air Auckland 2013
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What killed Amy Winehouse?
1. drug overdose
2 alcohol overdose
3 both the above
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Amy Winehouse's death due to acute
alcohol poisoning
Blood alcohol 450mg/%
= 5.5 x legal driving limit
Why not use this
to inform people
of the harms of
alcohol?
Despite being
in recovery
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What is a drug?
And who says?
Back to the science .
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The drinks industry?
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What is a drug?
something a politician once used but now regrets
Jaqui Smith (Home Sec)
I smoked cannabis but didnt enjoy
David Cameron (Prime Minister)
I did things when young that I I shouldnt have we all did
etc etc
Release
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What I say
a drug is
a chemical which when taken produces physiological changes
Which in relation to controlled drugs relates to
pleasurable/desirable effects in the brain
Or damaging ones..
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Death from drugs?
Gavin Britton Leah Betts
alcohol poisoning water poisoning following
MDMA use
(drinking game after Exeter
University golf match)
Note in newspaper Billboards all over the UK
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Drug related deaths - UK
10
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
Tobacco Alcohol Opiates
0
200
400
600
800
1,000
1,200
1,400
Source: Smoking and drinking among adults, 2009. Office for National Statistics
Drug Misuse Declared: Findings from the 2010/11 British Crime Survey England and
Wales. Home Office
Estimates of the Prevalence of Opiate Use and/or Crack Cocaine Use, 2009/10:
Sweep 6 report. The Centre for Drug Misuse Research
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Deaths for people under
age 65 from major diseases
compared with 1970 - UK
Nick Sheron Southampton
Liver disease
The inexorable rise of liver deaths
80% due to
alcohol
20% viral
Note in this period alcohol consumption
increased about 60%
-
14
0
500
1,000
1,500
2,000
2,500
16-24 25-34 35-44 45-54 55-64 65-74 75+Age group
Num
ber o
f dea
ths
0%
5%
10%
15%
20%
25%
30%
% o
f all de
aths
by a
ge g
roup
Wholly attributable conditions Partially attributable chronic conditions
Partially 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
100
200
300
400
500
600
700
800
900
1,000
16-24 25-34 35-44 45-54 55-64 65-74 75+
Age group
Num
ber o
f dea
ths
0%
2%
4%
6%
8%
10%
12%
14%
16%
% o
f all de
aths
by a
ge g
roup
Wholly attributable conditions Partially attributable chronic conditions
Partially 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)
Male deaths from alcohol
http://www.nwph.net/nwpho/publications/alcoholattributablefractions.pdf
Alcohol the most common reason for death in men under 50
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Alcohol is the most destructive drug to the brain
Normal
Alcohol addiction
-
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)
0 10 20 30 40 50 60 70 80
Alcohol (units/week)
0 10 20 30 40 50 60 70 80
Alcohol (units/week)
0 10 20 30 40 50 60 70 80
Alcohol (units/week)
0 10 20 30 40 50 60 70 80
Alcohol (units/week)
5.0
4.0
3.0
2.0
1.0
0.0
Re
lati
ve
ris
k
5.0
4.0
3.0
2.0
1.0
0.0
Re
lati
ve
ris
k
5.0
4.0
3.0
2.0
1.0
0.0
Re
lati
ve
ris
k
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
UK government
refused to act
on alcohol
because of this
minor beneficial
effect!
Wide impact of alcohol on human diseases
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What about cannabis?
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Rise in incidence and prevalence of cannabis use since 1970 in England and Wales (Hickman et al 2007, Addiction 102, 597-606)
Ever use
Period prevalence
Incident
Cannabis < 18
20x increase in cannabis users over last 40 years
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Self-reported cannabis use and prevalence/incidence rates of schizophrenia and
psychoses in England, 1996 to 2005/06
0
5
10
15
20
25
1996
1998
2000
2001
/200
2
2002
/200
3
2003
/200
4
2004
/200
5
2005
/200
6
Annual prevalence rates ofschizophrenia and psychosesper 10,000 PYE
Annual prevalence rate ofschizophrenia per 10,000 PYE
Annual incidence rates ofschizophrenia and psychosesper 10,000 PYE
Annual incidence rates ofschizophrenia per 10,000 PYE
If anything schizophrenia is declining
Frisher et al (2009) Weissenborn and (Nutt 2011)
-
Self-reported cannabis use and prevalence/incidence rates of schizophrenia and
psychoses in England, 1996 to 2005/06
0
5
10
15
20
25
1996
1998
2000
2001
/200
2
2002
/200
3
2003
/200
4
2004
/200
5
2005
/200
6
Annual prevalence rates ofschizophrenia and psychosesper 10,000 PYE
Annual prevalence rate ofschizophrenia per 10,000 PYE
Annual incidence rates ofschizophrenia and psychosesper 10,000 PYE
Annual incidence rates ofschizophrenia per 10,000 PYE
If anything schizophrenia is declining
To prevent one case of schizophrenia one would
have to prevent 5000 young men from ever
smoking cannabis
ACMD 3rd cannabis report 2009
Therefore no need to reclassify from Class C
-
The MCDA 16 criteria of drug harm Multi Criteria Decision Analysis approach
Harm to self
Harm to others
-
Drugs ranked according to total harm
UK experts MCDA approach
Nutt King & Phillips Lancet Nov 2010
Alcohol
Cannabis
Tobacco
-
New European data 2013
ISCD European study FP7 2013 20 European countries
-
No correlation of UK Drugs Act
classification with MCDA results
22
0
1
2
3
4
5
0 20 40 60 80
UK
Dru
gs
Act
cla
ssif
icat
ion
ISCD results
A
C
B
U
linear r = 0.04
-
No correlation of UK Drugs Act
classification with ISCD results
23
0
1
2
3
4
5
0 20 40 60 80
UK
Dru
gs
Act
cla
ssif
icat
ion
ISCD results
A
C
B
U So the law is incorrect .. and therefore unjust (and ineffective)
May add to harms
And .impedes research and treatment developments
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How the media distort drug knowledge
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Police complicity: The Scunthorpe two (17/03/10)
Two young men found dead
Officers believe both lads had M-CAT (mephedrone) and also had access to heroin substitute methadone which they
used to bring them down from the high of mephedrone
- they had also been drinking heavily until 2am
Nick's dad wept as he urged youngsters to avoid the drug "I don't want him to be labelled a druggie because he wasn't.
He was just on a night out with friends enjoying himself, a
normal, caring, hard-working lad. (The Sun, 17/03/10)
Media clamor to get the drug banned
-
26
0
50
100
150
200
250
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Mephedrone becomes
available online
Source: Deaths related to drug poisoning in England and Wales, 2010,
Office for National Statistics
An unexpected benefit of mephedrone
Mephedrone
appears to have
reduced cocaine
deaths
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Perverse effect of banning mephedrone
replacement with more toxic analogues
0
20
40
60
80
100
120
140
-
Time for Enlightenment? Many banned drugs have potential as treatments
Cannabis pain spasticity nausea weight loss insomnia
MDMA to assist trauma therapy PTSD
Psilocybin for depression, cluster headaches, OCD
LSD for terminal illnesses
Ketamine depression and pain
Mephedrone & Naphyrone for treatment of depression and addiction
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Time for Enlightenment? Many banned drugs have potential as
treatments
Cannabis pain spasticity nausea weight loss insomnia
MDMA to assist trauma therapy PTSD
Psilocybin for depression, cluster headaches, OCD
LSD for terminal illnesses
Ketamine depression and pain
Mephedrone & Naphyrone for treatment of depression and addiction
The worst censorship
of research since ..
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The banning of the Heliocentric
theory of the universe
1616 The papal Congregation of the Index banned all
books advocating the Copernican system of explaining
planetary motion - Not revoked until 1758
Galileo
Galilei
1564-1642 Giordano Bruno
1548-1600
Nicolaus
Copernicus
1473-1543
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To read more about this Nature Reviews Neuroscience June 2013
www.nature.com/nrn/journal/vaop/ncurrent/abs/nrn3530.html
http://drugscience.org.uk/blog/2013/06/11/lets-get-war-drugs-out-our-hospitals-and-
laboratories/
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Two Nobel prize winners who used LSD
Francis Crick Kary Mullis (PCR)
Double Helix Polymerase Chain Reaction
Before it was banned
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No problem can be solved from the same level of consciousness that created it Albert Einstein
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Clinical Interest in LSD in the
1950s and 1960s
Hundreds of psychiatrists worldwide
1000 clinical papers
40,000 patients
40 books
6 International conferences
Results were overwhelmingly positive, describing safe and effective treatments.
(Masters and Houston, 1971)
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One example
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LSD in alcoholism
Effect size >= all current therapies
Since the banning NO clinical trials only one neuroscience study
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LSD
Mescaline
Affinity for 5-HT2A
Potency in man
Glennon et al. 1984. Human dose data from Shulgin 1978
Resurrecting psychedelic research with psilocybin All these drugs stimulate 5HT2A receptors
Psilocybin magic mushrooms Short acting if used iv = 30 min effect
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PET image
[11C]Cimbi-36
5HT2A receptor
agonist
Copenhagen
5HT2A receptors most densely expressed cortex)
Note = agonist / high affinity state of the receptor as
[11C]Cimbi-36 an agonist
The 5-HT2A receptor in humans revealed by PET
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Our first Psilocybin Studies
unexpected decrease in rCBF
Carhart-Harris et al. 2012. PNAS
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Psilocybin attenuates activity in the brain
region that causes depression
Carhart-Harris
and Nutt PNAS 2012
fMRI BOLD image
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A number of effective treatments for depression suppress mPFC activity:
SSRIs Kennedy et al. 01 CBT Goldapple et al. 04 Sleep deprivation Gillin et al. 01 ECT Bonne et al. 96 Placebo Mayberg et al. 02 Deep brain stimulation Mayberg et al. 05 Ketamine Deakin et al. 08
Clinical trial funded by MRC with Profs
Curran and Piling UCL will start this year
IF UK drug regulations can be overcome
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C4: Drugs Live
The ecstasy trial Probably first ever funding of serious scientific study by TV company
MDMA research only possible through independent funding
Opportunity to demonstrate scientific process and get vital harm reduction info to public
John Snow
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5% of British soldiers returning from
combat in Iraq met the criteria for
PTSD
In US soldiers the incidence of PTSD
is as high as 18%.
More returning
soldiers from Iraq
and Afghanistan
have committed
suicide from
untreated PTSD than
ever died in the
conflict out there.
PTSD
-
Mithoefer 2009 44
0
10
20
30
40
50
60
70
80
90
100
Placebo MDMA
% w
ith
PT
SD
MDMA-v- placebo for treatment resistant PTSD % meeting PTSD diagnosis pre/post
Mithoefer et al Journal of Psychopharmacology 2010
80% of
MDMA
treated
group go
into
remission
-
Mithoefer 2009 45
0
10
20
30
40
50
60
70
80
90
100
Placebo MDMA
% w
ith
PT
SD
MDMA-v- placebo for treatment resistant PTSD % meeting PTSD diagnosis pre/post
Mithoefer et al Journal of Psychopharmacology 2010
80% of
MDMA
treated
group go
into
remission
Almost almost all responders
stay well when followed up
one year later
-
How does MDMA
work?
Reduces brain
blood flow
particularly in sub-
cortical regions
Carhart-Harris et al
Int J of
Neuropsychopharmacology
In press
-
Memory
responses
MDMA v- placebo
Enhanced
positive ratings
of good and
reduced
negative ratings
of bad
memories
Carhart-Harris et al Int J of Neuropsychopharmacology In press
-
MDMA effects: memory and fMRI
May explain
therapeutic potential
in PTSD Carhart-Harris et al Int J of Neuropsychopharmacology
In press
-
How illegal status distorts reason
Jan 2011 after BBC reported our psilocybin fMRI study
study Jim Dobbin MP demanded of the Drugs Minister
why was Professor Nutt allowed to use an illegal drug in a scientific study
2012 after the MDMA program on Nov 19th another PQ
what licences were held from her Department for the drugs used in the recent Channel 4 documentary on
MDMA; what is the process for revoking such
licenses and how this process would be initiated
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Sensible ways forward
Fully endorse harm reduction approaches at all levels
Improve understanding of relative harm
Take politics out of decision making independent experts decide
Accept that young people like to experiment protect from harm of all sorts at this stage - Including from criminalisation
Provide accurate and credible information
Remove penalties for possession for personal use
Gather evidence on the impact of drug classification
Introduce a class D category for new drugs
Ease the restrictive holding regulations for the study of illegal drugs encourage research e.g. on MDMA and psychedelic psychotherapy
-
Putting science in charge 1 MCDA on Nicotine products
Nutt et al submitted
-
Putting science in charge 2
A safe alcohol
A synthetic alcohol now within the scope of modern neuroscience
+ antidote
New Scientist 2006
The Scientist Jan 2011
Should have the same health benefits as snus
and ecigarettes have for cigarettes
-
Thanks and questions?
Read more about it
All proceeds to the
Independent
Scientific Committee
on Drugs = ISCD
www.drugscience.org.uk