IS THERE A RATIONAL BASIS FOR DIFFERENTIATING
DRUGS BY HARM POTENTIAL?
Paper presented at the 5th Conference on the Reduction of Drug-related harm, Toronto, 6-10 march 1994
As the title question of this session suggests, the present differentiation between drugs, between the legal ones and the illegal ones is considered irrational by the organisers of this conference, if not they would not have organised this session on this conference devoted to harm reduction. But even while being not rational in the eyes of many of us, I would like to pay attention to the present differentiation, if only to select eventual criteria for a more rational differentiation.
Subsequently I will pay attention to the considerations of the Dutch commission Baan that advised the Dutch government sucsesfully to differentiate between Cannabis and the other illegal drugs, supposed to be hard drugs.
Finally I will present you my conclusions.
The differentiation between legal and illegal drugs.
To start we have to realise that the present differentiation between the legal drugs, alcohol and tobacco, and the illegal ones like cannabis, cocaine and heroin, was and still is considered to be rational by many.
The basis for this differentiation is given in the Preamble of the 1961 Single Convention which states that the signatories of this treaty are concerned with the health and wellbeing of humanity1. The perceived harm to health and wellbeing that the use of illegal drugs inflicts on the user, and as such on public health is basis for the differentiation.
In addition, in the same preamble another aspect is mentioned: addiction2. Thus, another apparent basis for the existing differentiation of drugs is their perceived addictive property.
Their criteria; first: addiction.
Well, harm to health is more or less objective, and might serve as a rational basis for differentiation. I will therefore scrutinize this aspect later on. Harm to wellbeing is utterly subjective and in my view cannot serve as such. Finally, there is addiction. This is a very controversial aspect, if only because the word, although used very often, is so badly defined. We may say colloquially that somebody is addicted to eating, or to work (a workaholic). We talk about alcohol addiction, but we all know that there is a difference between the way the French regard alcohol addiction (if at least they feel it exists) and the Swedish outlook. Only when we consider addiction to drugs there seems to be a consensus about the meaning of addiction, but even so we cannot deny that the Dutch and the Germans have different connotations about the use of Cannabis, not to mention those of a Pakistani farmer. A Norwegian judge will regard daily khat-chewing in another way than his Yemeni collegue.
But even when we disregard these apparent differences, one might object that addiction, in the colloquial sense of the Single Convention, is not a rational basis for differentiation by itself. What is the harm of being addicted, one might ask? Tobacco seems to be highly addictive, but the harm inflicted by tobacco is not the addiction itself. The harm of addiction is mainly dependent of the availability. As long as tobacco is easily available, no smoker is worried by being addicted, but by the lungcancer and the heart disease it may cause.
I suggest, the concern of the signatories of the Single Convention with regard to addiction is of a moral nature and this moral parti-pris is an irrational basis for the actual differentiation. This can be illustrated by the fact that the 1971 Psychotropics Treaty of Vienna prohibited also non-addictive drugs as LSD by defining them as addictive.
This was based on an advice of a WHO Expert Committee3, that suggested the generally accepted notion of 'drug dependence'4 to be augmented with an addition relating it to a certain group of drugs in order to differentiate between the dependence on one group of drugs and that on another group of drugs, the laudable intention being to indicate that different types of drugs produce different types of dependence with different clinical syndromes and consequences5. Highly rational: the withdrawal syndrome of opiates differs from that of, say, alcohol or barbiturates. But the creation of drug dependence-LSD type was not rational at all as already everybody knew at that time that LSD does not create dependency of any type. But it had as a consequence that the hallucinogens are defined as addiction producing drugs, to be subsequently prohibited by the Vienna Treaty.
Although the position taken by the signatories of these international conventions and treaties is clearly moral as shown by the improper handling of the idea of dependency, it does not follow logically that dependency creating properties of a drug might not serve as a criterion to differentiate. The question is however whether or not we can measure the addictive properties of drugs. Some pharmacologists consider addictive property as a property of the substance. They use the paradigm of selfinjecting behavior of experimental animals as yardstick.
Although interesting from the point of view of a neuroscientist, to unravel the intricacies of the brains internal reward system, I feel these experiments to be less interesting when applied to the questions regarding addiction. Although there is some correllation between level of selfadministration and "addictive" property, I feel these experiments have little if nothing to say about actual human behaviour. The difference between cocaine and heroin may illustrate this. Most of us perceive heroin to be the most addictive of these two drugs, in the sense that most heroin users are "hard" users, while most cocaine users are "soft" users. The results of animal experiments however tend to show that cocaine is the stronger rewarding of the two. So there exists a clear discrepancy between the propertties of the drugs and the actual human behaviour with regard to "addiction". At least other factors, non pharmacological in nature, have an overriding influence on the outcome.
Thus, addictive properties of drugs cannot serve as a simple basis for the differentiation6.
Their criteria; health = toxicity.
Let us now consider the harm to health. The question is then: how does one measure the harmfulness of a drug? Pharmacologists might suggest that toxicity would be a usable yardstick to measure harmfulness.
Now, toxicity has many aspects: acute versus chronic toxicity, a third aspect is the therapeutic breadth (the difference between an active dose and the toxic dose). Toxicity is further influenced by route of administration. All together these are matters of pharmacology, of the properties of the drugs, and as such more or less objectively measurable.
For the present, we may conclude that toxicity might be a rational criterion for differentiation.
As a sideline, one might ask whether the harmfulness of the presently illegal drugs exceeds that of the legal ones, as is by example explicitly stated in the German Narcotic Law, das BetaubungsmittelGesetz, which bases its prohibition of some drugs on their harmfulness compared with the legal ones.
Some German judges have recently challenged their Narcotic Law as being unconstitutional, by stating that the legal drugs alcohol and tobacco are at least as harmful, if not worse than the illegal ones. They seem to have a point there. No pharmacologist will deny that alcohol is a lot more toxic than heroin or Cannabis. Brain damage due to alcohol being unequivocally proven, while even Nahas' worst pipe dreams are extremely questionable. I daresay the present differentiation cannot be defended by referring to differential toxicity, as a provisional ranking of drugs in decreasing order of chronic toxicity in my opinion would look more or less like: alcohol, tobacco, cannabis, cocaine, heroin, lsd.
Another differentiation: soft versus hard.
Let us now turn to another differentiation, the differentiation between the "soft" drug Cannabis and the other illegal "hard" drugs. In the past this differentiation has been proposed by a number of Commissions, among them the Le Dain commission in Canada. The athor trusts he will not be accused of nationalism, when taking the relevant Dutch Commission as example to discuss here.
When in 1972 in the Netherlands the governmental commission Baan, after its president, advised on drug-policy, which laid the fundament of the dutch drugpolicy, they made a risk-analysis which was not based solely on medico-pharmacological insights as discussed earlier, but took also social-scientific and psychological aspects of druguse into account.7
" A scale of dangers which is solely based on the pharmacological properties of the substance or on the physical or psychical harm that its use may inflict on the individual is no useful yardstick for the government. Not only are dosis, frequency of use and route of administration influencing the chance on harmful consequences for the individual, but also a host of other factors play a role in the calculation of this chance. Moreover, when considering whether and what measures have to be taken regarding the availability and the use of a substance, the government has to take into account those factors that create a chance on harmful consequences for society. The risk that the use of a substance implies not only for the individual but especially for society is dependent on all these factors together. This risk has to be the starting point for drugpolicy."
Risk as a criterion.
The Commission Baan sums up a large number of factors to decide upon the risk of drug use:
- 1. the pharmacological properties of the substance, the development of tolerance as a measure of "addiction" being very important in their view, but they recognised that this is not only highly dependent on dose, route of administration and frequency of use, but as well of the personality of the user (sensitivity for the substance, personality structure, mood and expectations regarding the effects.
- 2. the possibility to dose properly (among others dependent of he possibility of standardisation).
- 3. the eventual users (age, profession)
- 4. eventual circumstances in which the use is unacceptable because of danger to others (worksituation, traffic) and the possibility to verify and evaluate the use under these conditions both instantaneous and later;
- 5. the possibility to regulate and channel production and distribution; the possibility to reglement and to install norms regarding the use.
Not only did the Commission realise that effects of psychoactive drugs are the result of the three factors: drug, set and setting thus anticipating Zinberg8, but they concluded as well that integrated use of drugs is possible and that the associated risks are sometimes acceptable. They performed a such a risk analysis for Cannabis and concluded that the use of Cannabis implied an risk acceptable for society. It may be surprising that they did not perform identical risk-analyses for the other illegal drugs, but we have to realise that at that time the noun "junkie" did not exist in the Netherlands and that "hard drugs" meant opium and lsd, which were cheap and relatively easily available.
If a body as representative and independent as the Baan commission could repeat such an analysis today, in the light of the present Dutch experience with drugs they would probably end with a ranking like heroin, cocaine/lsd, XTC, Cannabis.
This listing would clearly not be based on toxicity, but on perception of risk, as perceived through dutch spectacles.
Drug, set and setting.
What the Baan commission taught us, and I believe as to be fundamental for dutch drugpolicy, is what Zinberg later explored: drug effects are the result of drug, set and setting. When we differentiate only on the all togeter rather flimsy basis of the drugs pharmacological properties, colloquially equated with "toxicology", as measure for harm, we deny the influence of the other other factors: set and setting.
To discuss set, we need psychologists and maybe an occasional psychiatrist, and as these fields are not my competence I cannot say more than that I have the strong feeling that individual cases should never influence policy decisions influencing millions of people. Let's say that these factors are largely intangible for policy, although I cannot deny my impression that, as an example, the drinking behaviour of Swedish people having their holidays in the Mediterranian countries is more the result of Swedish alcohol policy strongly influencing their mindset, than of the mediterranean setting.
This brings me to the last set of variables influencing the drug effect: setting.
On the micro level this is rather difficult to influence, a number of presentations on this conference describe how people try to do this at the mesolevel, but on the macrolevel policy can strongly influence the setting.
Returning to the simple ranking I suggested earlier: heroin, cocaine/lsd, XTC, Cannabis, this is a ranking reflecting the present dutch perceptions. And for policy these perceptions are reality. This is to say that this ranking is my perception being a Dutchman, so my present practical policy would be based on this perception. Living in another cultural environment my ranking would certainly be different. The cultural framework surrounding the use of any psychotropic substance is to my perception overridingly decisive for the effects of this substance. The drugs that I regard as the most toxic, alcohol and tobacco, are also those that I use most. In my cultural framework those are too the drugs that are the easiest to handle, even to the point that I have little difficulties to adapt to the north-american attitude to smoking tobacco. In another cultural framework the "easiest" drugs might be ayahuasca, the user being a Sao Daime follower or speed if he is an australian truckdriver, not to deny the problems some of them experience, but society has an answer. An answer that relates the user to the community and more important the community to the user.
Even when prohibition has become history as the burning of witches is now to us, each culture, each society will have its own drug preferences and associated rituals. The Swedish then deserve prohibition!
So I have my differentiation. Whether this is a rational or an irrational one, is for you to decide. As far as I try to involve setting in my differentiation I am able to rationalise it. But in my capacity as "psychopharmacological expert" as the conference organisers had me flatteringly announced, I find no rational basis for differentiation between drugs.
1"-concerned with the health and welfare of mankind, -recognizing that the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering and that adequate provision must be made to ensure the availability of narcotic drugs for such purposes, etc."
2 Recognizing that addiction to narcotic drugs constitutes a serious evil for the individual and is fraught with social and economic danger to mankind, etc."
3 WHO techn.Rep.Series 1964, 273, 9.
4 drug dependence "always include(s) a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence". WHO techn. rep. series 1969, 407,6
5 Cameron,D.C. (1970): Some psychosocial aspects of drug dependence. J.Mond.Pharm. 13(3), 246-258.
6 Peele,S.: The meaning of addiction.D.C.Heath & Comp., Lexington, 1985.
7 Achtergronden en risico's van druggebruik. Staatsuitgeverij, s-Gravenhage, 1972, pg 64.
8 Zinberg,N.E.: Drug, set and setting: the basis for controlled intoxicant use. New Haven, Yale University Press, 1984.
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