Examination of Witnesses (Questions 400-419)
PROFESSOR COLIN
BLAKEMORE, PROFESSOR
JOHN STRANG
AND MR
ANDY HAYMAN
26 APRIL 2006
Q400 Chairman: When Brian Iddon raised
this issue of the connect between a particular drug and crime
the answer was that there is not a research base on which we can
deliver the evidence in order to reform policy, and yet you have
responsibility in many ways of delivering that research.
Professor Blakemore: I think there
are some correlations between drug use and behaviours and their
social impact which are very well documented. I think the police
are in the best possible position to provide evidence about those
relationships. For instance, the effect of alcohol and its impact
on families, the tendency to produce aggression and violence;
the same with crack cocaine—the link between violent behaviour
and crack cocaine is very well established. I think when we talk
about assessing drugs according to their harm it is very important
to emphasise that we should not just be talking about medical
harm—toxicity, damage to the body and the user—but
the general impact on society. I think if we look at the impact
of drugs in the last forty or fifty years the biggest effect has
been on society rather than users. We know that 90% of drug related
deaths are attributable to alcohol and tobacco, and much of the
remainder to methadone (prescribed methadone, at least initially
prescribed and then illegally available methadone). We have to
take into account the social impact of drugs when considering
their harms.
Professor Strang: One of the reasons
you do not have answers to your questions is that the UK does
not invest in getting the answers. We are junior players when
it comes to funding research that studies impact. If you look
at the US and Australia they are orders of magnitude greater in
investment. Our investment of our expenditure is about 0.1%; they
operate at between 1 to 4%. I am not just saying there should
be a little bit more. It is an embarrassment and it means that
people like myself and my colleagues get lured away. Australia
is populated by ex-pat addictions researchers who created a critical
mass because of a better research funding environment. Supporting
Andy Hayman's point, it may seem strange that people this side
of the table are saying that it has less significance than perhaps
your attention to it, but our interest is in the law as it is
applied; it is not the same as what the paperwork says. Let is
look at the cannabis example, if I remember the figures correctly
between the mid-80s and mid-90s cautioning became what happened
with more than 50% of all cases. No change in the law occurred;
it was how at a local level a change occurred. You ought to want
to know and I ought to want to know whether that led to increased
use? What did it lead to? There is not really any answer to that.
Our interest needs to be in the law as it is applied, not some
letter that is attached to it.
Q401 Mr Newmark: To what degree is
the lack of both medical and social evidence in this area a limitation
in determining the appropriate classification of drugs? In your
experience how well does the Advisory Council cope with the challenge
of making decisions on the basis of inconclusive evidence?
Professor Blakemore: I think I
would challenge what you say about the availability of evidence
on the medical effects of drugs. This is a rapidly moving, expanding
field of knowledge. I am sure that John would say that because
of funding this country is not in a position to make as big a
contribution to that knowledge as we should. We know a great deal
about how drugs act on the brain and how, in some cases they produce
dependency or addiction, what their toxic impacts are and therefore
what the medical implications are. There has, of course, also
been a great deal of research on the social impact of drugs. I
am no expert and I am not in a position to say whether that evidence
is as full as the scientific and medical evidence. The problem
is—and perhaps this is at the heart of your question—that
evidence is never perfect; it is changing. That is the basis of
science and the collection of data. For instance, five years ago
I would have said that the evidence for a causative link between
cannabis use and the precipitation of psychotic episodes was extremely
low. I have changed my view; I think the evidence is overwhelmingly
clear. The effects are small but definite.
Q402 Mr Newmark: That is because
cannabis itself has changed and people are making it stronger.
Professor Blakemore: No, I do
not think it is. We know the genetic basis of those effects now
through work funded, I am glad to say, by the Medical Research
Council at the Institute of Psychiatry, and we have a very good
rational explanation for those effects. It is a very small effect
but it exists. That, of course, gets to the heart of one of my
concerns about the ABC system. Because it has these sharp boundaries
between As and Bs and Cs it is quite difficult to move drugs around
in the classification on the basis of new evidence; but science
is constantly throwing up new evidence.
Professor Strang: I would agree
with much of what Colin Blakemore is saying. We do have an increasingly
good picture for understanding drug effects and drug problems
in the sort of classic high tech science way. However I would
actually like to draw your attention to the potential danger of
that. As we have increasingly impressive scientific techniques,
what we are likely to lose out on is low technology science that
looks at things like the impact of whether at a low level of policing,
a change to cautioning, leads to an increase or decrease. I think
we crucially need to know that. But that type of proposed research
would not have a snowball's chance in hell of getting funded as
a project compared with someone imaging some particular bit of
the brain that helps you understand how it works. Even though,
in terms of answering the question that alters how you apply the
law and how you run society, in my view it is much more valuable.
Some mechanism for protecting lower technology policy type scientific
studies is urgently required and the funding pressures on science
means that there is likely to be even more of a contrast between
the things that do get funded at the high technology end.
Q403 Mr Newmark: In order to improve
the way we go about classifying we need more evidence; in order
to get more evidence we need more money into doing the research.
Is that what you are saying?
Professor Strang: I think so,
but in terms of gathering more evidence you could go on in this
field forever about getting a portfolio of information. But the
special missing element in the existing research is an exquisite
series of experiments of opportunity. You can easily list a dozen
things where, if you knew that the changes you had made with temazepam
capsules in the late 90s had led to less use and less harm because
rescheduling or reformulation took place then you would be more
confident about making a similar change with another drug. If
you knew it had backfired on you and had gone the opposite direction,
you would be pretty hesitant about going the same way again. You
do not have that partly because a lot of your research machines
are in-house government department research where the vested interest
is in making sure that the departmental decision or ministerial
decision is propped up against criticism.
Q404 Chairman: Do you think, yes
or no, that ACMD is in fact coping with this agenda? Is it the
right organisation, the right body, the right set up to actually
deliver what is being asked of it?
Professor Blakemore: In a single
word, yes. It has the right range of expertise. It takes a lot
of time and trouble in considering the evidence. If there is a
deficiency in the system I would say it is in the mechanism for
communicating.
Q405 Chairman: It does not commission
any evidence. It does not do any research.
Professor Blakemore: It does not
need to do research; research is available, published. It looks
at the available literature. Perhaps it would be useful if it
could feed better into policies and the setting of policy priorities
and strategies. That might be a valuable role, but I think the
principal deficiency is how that huge mass of knowledge in the
Advisory Council is able to feed into policy. And that is a reflection
I think on the Misuse of Drugs Act classification.
Mr Hayman: My answer is yes. I
do not know whether members have had the opportunity to go along
and sit in and witness what goes on in the ACMD. I have been participating
in workshops, weekends away and also the full meetings. I challenge
the notion that you have to have them commissioning any research
because actually they are blessed with the experts in the room.
Chairman: I will leave it at that because
we will be coming back to it.
Q406 Mr Newmark: Professor Blakemore,
you have been making presentations on the concept of a scientifically
based scale of harm for some years. When did you first draft the
paper with David Nutt and others proposing this scale? My next
question is, why has there been a delay in submitting it for publication?
Professor Blakemore: I did not
draft the paper; David did; he is the first author and I think
it must have been about 18 months ago.
Q407 Mr Newmark: I am curious as
to why it has not been done. There are these scales that are out
there to do with physical harm, dependence and social harms and
in some ways it struck me that you are trying to make a science
out of an art, particularly when it comes to social harms. I am
curious as to why this analysis has not been published yet.
Professor Blakemore: It sometimes
takes quite a time to get a scientific paper, particularly with
four authors, into a form that everybody accepts is ready for
publication. If I could explain the basis of the study, it did
grow out of talks that I gave on the possibility of creating a
sort of matrix in which numerical values could be given to assessments
of harm in order to rank drugs, not just illegal drugs but also
including the familiar, acceptable, legal drugs as a kind of calibrator
for the scale as a whole. An 18 month delay in getting a paper
ready finally ready for publication is not unusual, I am afraid,
in science.
Q408 Mr Newmark: Are you in favour
of using a scientifically based scale of harm to determine the
legal status of drugs?
Mr Hayman: If I could see the
detail of what that looked like I could give an opinion on it
but I would be worried that we are just shifting from a classification
process at the moment to a different style one which would still
have the frailties that are currently in the present system.
Q409 Chairman: The concern is that
on that scale of harm alcohol, ketamine, tobacco and solvents
are all incredibly high up on the categories and yet none of them
appear in any of the classifications at all. That is a concern
we would have.
Professor Blakemore: I think the
most striking conclusion from the study is that although it purports
to do what the Misuse of Drugs Act says is the basis of its classification
the result is not statistically correlated with the ABC classification
at all. In the ranking of drugs according to nine categories of
harm of the top eight most highly ranked drugs in terms of harm
three were Class A drugs and two were legal (at the time legal—ketamine
has just been classified as C). Of the bottom eight, in terms
of harm, two were legal (khat and alkyl nitrites) and three were
Class A drugs (LSD, ecstasy and 4-methylthioamphetamine).
Q410 Mr Newmark: I have to come to
the conclusion then that part of the delay in coming out with
this publication is that having come up with these parameters
they are not quite fitting with your argument because of these
other drugs that have been mis-categorised based on historical
evidence of the way they have been categorised.
Professor Blakemore: I do not
think that it is our argument. What it implies is that one of
the ways of classifying drugs according to harm—the ABC
system or ours—is wrong, or they are both wrong. They certainly
do not agree with each other.
Q411 Margaret Moran: Professor Strang,
I think the point you are making about the lower level research
is very important. The fact that that research has not been done,
is that a reflection on the effectiveness—or lack of effectiveness—of
ACMD? Who should be commissioning that research?
Professor Strang: I think the
lack of this type of research severely handicaps the ACMD and
it severely handicaps government's process of making decisions.
Personally I think it would be ill-conceived to expect ACMD to
be the body that commissioned work of this sort ACMD needs that
work to be done, but its membership is not the right kind of membership
for trying to get good quality work done that feeds into it. I
have had either the privilege or the curse in previous times of
being on ACMD, and that type of research needs to be done—but
ACMD is the wrong type of body to conceive, consider or commission
the specific research.
Q412 Margaret Moran: Who should be
commissioning it if not ACMD? They are supposed to be the body
who advises on it; surely they should be making the very point
that you have been making.
Professor Strang: I think if you
looked around the room at ACMD you would see very few people with
a research pedigree. It would be an unfair request to ask ACMD
members to adjudicate between a good proposal versus a poor proposal.
I think they need that to be done just like Parliament needs it
to be done, but then that is different from it being the commissioner
of it. You would like to say that government departments with
interest and responsibility in the area were the obvious people.
However we must have serious doubts about that because I think
they become pre-occupied with just blindly defending the decision
that was made yesterday. What you want, what we need, is an investigation
that has enough integrity and independence to be able to say that
it was a well-intentioned decision but actually it has backfired
and that is completely missing. I do not think the ACMD would
achieve that; it would still have that heavy hand of the civil
service on it.
Q413 Margaret Moran: What you are
suggesting then is that ACMD is not sufficiently independent of
the Home Office secretariat. Is that what you are telling us?
Professor Strang: I do not think
that was what I was saying but I would have thought that probably
is a correct observation.
Q414 Margaret Moran: What about the
other members of the panel? Would you say that ACMD is not sufficiently
independent of the Home Office?
Mr Hayman: I am not in a position
to be able to comment on that; I just do not know.
Q415 Chairman: You are on it.
Mr Hayman: I might be on the ACMD
but I do not have a clue what the secretariat of the Home Office
does so therefore I am not in a position to be able to comment.
Q416 Margaret Moran: I am talking
specifically about membership of the ACMD.
Mr Hayman: I am independent of
the Home Office and I am on it.
Professor Strang: I was not referring
to the members as individuals; I was referring to the body of
this operation. I am sure the individuals have independence and
integrity outside the process.
Q417 Margaret Moran: There is a suggestion
that as currently constituted there is insufficient breadth of
experience on ACMD. There is a suggestion that the breadth of
expertise on ACMD is not sufficient to address the questions that
it is being asked to deal with. Is that your view?
Professor Blakemore: It is a very
big committee with a wide range of expertise. You are raising
a very important issue about whether ACMD should be in a position
to commission research. It is music to my ears that John would
say that history shows that the best way of getting good research
done is to do it independent of ministerial control. We know of
examples in which research commissioned by a government department
has produced the results that the department has wanted—there
is an understandable tension. On the other hand if, in the research
councils—which is where the independent research is done—there
is no response to policy needs then there is a kind of disconnect
between where the high-quality work is done and what government
needs to know. It is joining up those two things which I think
we need to think about carefully. We have a very good opportunity
to do so in the medical field with the proposal that the funding
of the Department of Health R&D and the Research Council funding
of medical research might be conflated in some new way. This not
only would increase the money for addiction research and other
areas of research, but also perhaps give us a way to re-think
the input of policy questions into independent research.
Professor Strang: It seems to
me that you need to recognise the vulnerability of the field and
where you look at countries that have deliberately pump primed
the process (the US went from zero in the 1960s through to producing
an amazing addictions research machine, so did Australia in the
1980s) you would have to protect the operation of that otherwise
it just gets trampled underfoot with the bigger research players.
That would be resisted because you would normally say: Throw it
in the market place and the best researchers and topics will win.
But with this one you would have to say: We have a special need
to make sure that we support this. With the drug addiction research
machine in the US we are talking of just over $1 billion per annum
for NIDA (the National Institute on Drug Abuse), so where I say
we are of a different order of magnitude, we are several orders
of magnitude out and what we end up with in the UK is a Mickey
Mouse operation compared with others.
Professor Blakemore: Could I say
that I was glad you introduced me as being both from Oxford and
being from the MRC. What I have said so far has been, as it were,
as an independent academic but what I can talk about on behalf
of the MRC are the figures for spend. In 2003 to 2004 we spent
£2 million in total out of a £450 million budget on
addiction research. The total budget of the three NIH institutes
that work in this area is $2.9 billion so even if one takes a
conservative estimate of how much of that is actually devoted
to addiction research it comes out to about five hundred times
higher than in the UK—in other words about a hundred times
more per head of the population.
Q418 Chairman: If you take an issue
like young people and drugs and the effect, for instance, that
it has on young people's learning, I would have thought that the
MRC or indeed something which would be commissioned through the
ACMD ought to be looking at that specific area rather than just
saying "we think" and yet we do not. I am sure you would
agree with that.
Professor Strang: The current
position in which the MRC and any funding body operates is: Does
that compete with some other high technology bid? It will not,
and your choice is then to leave it in the market place and say
that if it sinks we will have to do without it or to say that
it has such importance to our societal process that we must protect
it. There are special themes in all sorts of research initiatives
and that would be a proper way of addressing it and that is currently
absent.
Q419 Chairman: I just think perhaps
that ACMD ought to have a budget or at least the power to be able
to commission some of that research.
Professor Strang: They should
certainly be able to identify areas where they felt handicapped
by not having answers.
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