Dr. David Nutt on Alcohol

Rebutting industry myths.

A couple of years ago, the European Alcohol Policy Alliance, known as EuroCare, put together a brochure addressing the common messages the liquor industry attempts to drive home through its heavy spending on advertising. The messages are not just designed to sell product, but also to influence alcohol policy at the political level. According to EuroCare, the “industry”—the alcohol and tobacco companies—“has traditionally worked closely together, sharing information and concerns about regulation. They have used similar arguments to defend their products in order to prevent or delay restrictions being placed on them.”

I wrote a blog post on EuroCare’s list of alcohol untruths called “7 Myths the Alcohol Industry Wants You to Believe." Here they are:

Message 1: Consuming alcohol is normal, common, healthy, and very responsible.

Message 2: The damage done by alcohol is caused by a small group of deviants who cannot handle alcohol.

Message 3: Normal adult non-drinkers do not, in fact, exist

Message 4: Ignore the fact that alcohol is a harmful and addictive chemical substance (ethanol) for the body.

Message 5: Alcohol problems can only be solved when all parties work together.

Message 6: Alcohol marketing is not harmful. It is simply intended to assist the consumer in selecting a certain product or brand.

Message 7: Education about responsible use is the best method to protect society from alcohol problems.

Recently, I ran across a great response to these same 7 myths by Dr. David Nutt, the British psychiatrist perhaps best known in the states as the scientist who got fired a few years ago from his post on the government’s Advisory Council on the Misuse of Drugs. Nutt’s primary sin was to suggest that, on a straightforward calculation of risks and harms, horseback riding was probably a more dangerous activity than taking the drug Ecstasy. The Home Secretary at the time insisted that you couldn’t compare a legal activity to an illegal one, or something like that, and Nutt compounded his sins by suggesting that marijuana was a safer drug than alcohol. British politicians took a serious dislike to him, the more so since most of the published medical science was on his side. After the dust settled, Nutt was one of the primary founders of the Independent Scientific Committee on Drugs (ISCD), formed to offer alternative views on drugs and addiction grounded in science.

Anyway, in his book, Drugs Without the Hot Air, Nutt has his own responses to the 7 Myths, which I excerpt here:

1. Consuming Alcohol is Normal: It’s normal, so long as you have the “normal” high-activity variant of the ALDH2 enzyme. If you don’t have that form of the enzyme, Nutt reminds his readers, as many Asians and Aleuts do not, then alcohol will affect you quite non-normally through the so-called alcohol flush reaction. Moreover, many cultures and societies unfamiliar with its effects “suffer hugely when new types of alcohol appear, particularly if they are aggressively marketed.”

2. Alcohol damage is caused by a small group of deviants: According to Dr. Nutt, statistics show that “millions of people, NOT a tiny minority, suffer harm from their own alcohol consumption, or cause harm to others…. It is the everyday drinking of people who have come to see alcohol as an essential part of life rather than the luxury it used to be, that has created a spike in cancers and stomach problems, and will see liver disease match heart disease as the leading cause of death in the UK by 2020.”

3. Normal adult non-drinkers do not exist: The alcohol industry is forever reminding politicians of how unpopular alcohol restrictions are to the voting populace. “The existence of non-drinkers obviously threatens this portrayal of society, so the industry tends to dismiss them as having something wrong with them. While some teetotalers are recovering alcoholics, many others have made a positive choice not to drink.” And there are others, I would add, often referred to as “sick” teetotalers, who have quit drinking for medical reasons unrelated to alcoholism.

4. Ignore alcohol’s harm to the body: Nutt reminds us that “there is no other drug which is so damaging to so many different organ systems in the body…. Most other drugs cause damage primarily in one or two areas—heart problems from cocaine, or urinary tract problems from ketamine. Alcohol is harmful almost everywhere.”

5. Alcohol problems can be solved when everybody works together: “In practice, what the industry means by ‘working together’ is bring in voluntary codes rather than statutory regulation—solving problems through rules that the industry CHOOSES to comply with, rather than laws which they MUST comply with.”

6. Alcohol marketing is intended to assist consumers in selecting products: Specifically, 800 million British pounds every year for advertising and promotion, according to Nutt. That’s just the kind of civic-minded bunch those alcohol sellers are. The reality, of course is that “marketing communications do have a marked effect on consumption…. All this further entrenches the false division between alcohol and illegal drugs, persuades people that consuming alcohol is safe, and makes realistic discussions of the harm alcohol causes very difficult.”

7. Education about responsible use is the best approach: “It is useful for the drinks industry,” Nutt explains, “to emphasize the value of education, because it takes the focus off regulation…. There is also extensive evidence gathered by the WHO from around the world, showing that merely providing information and education without bringing in other policy measures doesn’t change people’s drinking behavior.”

As I wrote in my original post: Who could be against the promotion of responsible alcohol use? Irresponsible zealots and deviants, that’s who. Why should all of us happy drinkers be made to suffer for the sins of a few rotten apples?

Indeed, all of the messages, overtly or covertly, send the same signal: You should drink more. It’s good for you.

Graphics Credit: http://www.holyrood.com/2011/04/at-what-price/

X-ed Out.

Another look at MDMA and serotonin.

A study by Canada’s Centre for Addiction and Mental Health (CAMH) has confirmed earlier findings that chronic users of ecstasy (MDMA) have abnormally low levels of serotonin transporter molecules in the cerebral cortex.

While a decade of research on the effects of ecstasy on brain serotonin has been controversial and largely inconclusive, the latest study used drug hair analysis to confirm levels of MDMA in 49 users and 50 controls. An additional division was made between chronic X users who also tested positive for methamphetamine, and those who did not. Regular usage of MDMA was defined as two tablets twice a month.

The Canadian study, funded by the U.S. National Institute on Drug Abuse (NIDA) and published in the journal Brain, suggests that the serotonin surge responsible for ecstasy’s effects results in a net depletion in regular X users. That is not a new finding--but the Canadian study goes further, suggesting that the serotonin depletion is localized in one area of the brain.

“We were surprised to discover that SERT was decreased only in the cerebral cortex and not throughout the brain,” said study leader Stephen Kish in a press release, “perhaps because serotonin nerves to the cortex are longer and more susceptible to changes.”

Low serotonin transporter (SERT) levels in the cerebral cortex were found in all X users, with or without amphetamine. Dr. Kish noted that the CAMH findings replicate what Kish referred to as “newer data” from Johns Hopkins University. In 1999, a controversial serotonin study of ecstasy users at Johns Hopkins laboratory was criticized for overestimating the level of danger posed by ecstasy-induced serotonin impairments.

Okay, the finding is becoming more robust. But what does it mean? According to co-author Isabelle Boileau, a low SERT level does “not necessarily” indicate structural brain damage. “There is no way to prove whether low SERT is explained by physical loss of the entire serotonin nerve cell, or by a loss of SERT protein within an intact nerve cell.”

For his part, Dr. Kish indicated that his concerns centered on the connection between lower serotonin measurements and MDMA tolerance levels. “Most of the ecstasy users of our study complained that the first dose is always the best, but then the effects begin to decline and higher doses are needed,” he said. “The need for higher doses, possibly caused by low SERT, could well increase the risk of harm caused by this stimulant drug.” The published study concluded that “behavioural problems in some ecstasy users during abstinence might be related to serotonin transporter changes limited to cortical regions.”

However, in addition to the confounding variable of methamphetamine (see my post, “How Pure is Ecstasy?”), it remains unclear whether the SERT alterations detected in the study are transient or permanent. Moreover, the nature of the link that “might” exist between lower SERT levels and cognitive impairment in the brains of regular ecstasy users remains a subject of dispute in the drug research community, as in this earlier post.  (And just to emphasize that drugs are complicated things, a spate of promising recent research has suggested that ecstasy might be an effective option for treating people with post-traumatic stress disorder).

The CAMH, affiliated with the University of Toronto, is Canada’s largest mental health and addiction teaching hospital.

Kish, S., Lerch, J., Furukawa, Y., Tong, J., McCluskey, T., Wilkins, D., Houle, S., Meyer, J., Mundo, E., Wilson, A., Rusjan, P., Saint-Cyr, J., Guttman, M., Collins, D., Shapiro, C., Warsh, J., & Boileau, I. (2010). Decreased cerebral cortical serotonin transporter binding in ecstasy users: a positron emission tomography/[11C]DASB and structural brain imaging study Brain DOI: 10.1093/brain/awq103

Graphics Credit: pubs/teaching/teaching4/Teaching3.html

How Pure Is Ecstasy?

Dutch study of street MDMA.

For 16 years, the Drugs Information Monitoring System (DIMS) in The Netherlands has gathered and analyzed tablets of purported MDMA sold on the street as Ecstasy. In a research report published in Addiction, Neeltje Vogels and others at the Netherlands Institute for Mental Health and Addiction in Utrecht found that between 70 to 90 % of the samples submitted as MDMA were pure. The most common non-MDMA adulterant was found to be caffeine.

The study covered the years from 1993 to 2008. In the mid to late 1990s, researchers saw an increase in ephedra and methamphetamine in the samples, and sample purity hit an all-time low of 60% in 1997. The years from 2000 to 2004 were the golden era, so to speak, for MDMA purity. “After 2004,” the study authors write, “the purity of ecstasy tables decreased again, caused mainly by a growing proportion of tablets containing meta-chlorophenylpiperazine (mCPP).” mCPP belongs to a class of stimulants, the so-called piperazines, that have been banned in several countries (See my post).

As noted on the DrugMonkey science blog, a lack of consistent published data has hampered efforts at studying street MDMA. Tablets for analysis are obtained either from law enforcement—which seizes drugs that may or may not be for sale at the club level--or drug analysis and harm reduction sites. The problem, DrugMonkey writes, is that “perhaps Ecstasy found to result in suspicious subjective effects on the user are submitted to harm reduction sites preferentially.” In other words, people only submit the brown acid.

The Dutch study, on the other hand, obtained samples for testing from capsules seized by club owners and given to the police, who then passed them on to DIMS for analysis. This system helped eliminate the possible bias effect of voluntary submissions.

The study also found that larger tablets, containing 100 mgs or more of MDMA, became increasingly popular starting in 2001.

DrugMonkey, an anonymous NIH-funded biomedical researcher, calls the study “an impressive longitudinal dataset.” The data, he wrote, give us “a good picture of the percentages of MDMA-only across time (higher than certain MDMA fans seem to acknowledge when it comes time to assess medical emergency cases) and the relative proportions of specific contaminants (certain baddies are quite rare.)”

Specifically missing in action most years is the baddy known as PMA, or para-methoxy-amphetamine, which has been implicated in many of the alleged Ecstasy deaths by overheating--a condition known as hyperthermia.

Graphics Credit: National Institute on Drug Abuse


addiction drugs

Arguing About Ecstasy

U.K. professor says “E” no riskier than horseback riding.

Professor David Nutt of Bristol University and Imperial College, London, stirred up a hornet’s nest of controversy last week when he compared the dangers of the club drug Ecstasy (MDMA) to people’s addiction to horse riding. In an article titled "Equasy: An overlooked addiction with implications for the current debate on drug harms,” published in the Journal of Psychopharmacology, Professor Nutt wrote: "Drug harm can be equal to harms in other parts of life. There is not much difference between horse-riding and ecstasy."

What makes all of this interesting is that Professor Nutt serves as the chairperson of the Home Office's Advisory Council on the Misuse of Drugs (ACMD), which will rule next week on whether ecstasy should be downgraded to a Class B drug in the British drug classification system. Drug treatment activists and government ministers immediately called for his resignation, saying Nutt was on a "personal crusade" to decriminalize the drug.

The BBC News Service reported that a Home Office spokesperson said recently that the government believed ecstasy should remain a Class A drug. "Ecstasy can and does kill unpredictably. There is no such thing as a 'safe dose'," he said.

Horse-riding accounts for 100 deaths or serious accidents a year in the U.K., according to Nutt. “Making riding illegal would completely prevent all these harms and would be, in practice, very easy to do.” In contrast, recent figures indicate about 30 deaths attributed to ecstasy use in the U.K. last year. “This attitude raises the critical question of why society tolerates - indeed encourages - certain forms of potentially harmful behaviour but not others such as drug use," Nutt wrote.

In an article by Christopher Hope in the Daily Telegraph, Nutt said: "The point was to get people to understand that drug harm can be equal to harms in other parts of life.” He cited other risky activities such as “base jumping, climbing, bungee jumping, hang-gliding, motorcycling," which, he said, were more dangerous than illicit drugs.

An ACMD spokesperson said: "Prof Nutt's academic research does not prejudice the work that he conducts as chair of the ACMD."

According to the Telegraph article, there are 500,000 regular users and between 30 million and 60 million ecstasy pills in circulation in the U.K.

In a letter published by the Journal of Psychopharmacology two years earlier, Professor Nutt used a more apt comparison to make the same point:

“The fact that alcohol is legal and ecstasy not is merely an historical accident, not a science-based decision. Alcohol undoubtedly kills thousands more people each year than ecstasy.... Many relatively ill-informed and indeed innocent young people will continue to die and many more will end up with the destructive consequences of alcohol dependence or physical damage. If the same effort currently used to deter ecstasy use was put toward reducing alcohol misuse the situation might improve.”


Photo Credit: Foundation Antidote