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Introduction
Ourproject focuses on the drug classification system in the UK, looking at whether or not the system needs to be reevaluated. Our project involves an audit of clinical data taken by doctors, from patients who present with drug addiction problems. This data is noted and recorded on aTreatment Outcome Profile (TOP)form and looks at the patient’s: physical health, mental health, social function and any criminal involvement. From a large enough pool of this data we believe we can establish which drugs have the most negative effects and whether this is reflected in the current classification system. In addition to the analysis of the TOP forms, we will also be reviewing past literature to provide a deeper insight on the matter.
The TOP forms cover alcohol, cannabis, opiate, crack cocaine, cocaine and amphetamine use. The forms are filled in at an initial client meeting and at review appointments with a doctor at the clinic. The clients of the rehabilitation clinic are asked how many days per week they have taken adrug, along with the amount they take daily. They are then questioned on injecting behaviour, criminality, social function and areasked to rate their psychological health, physical health and overall quality of lifeout of 20. The client themselves is asked for all the answers to the question, but the doctor discusses with them to ensure that the results give an accurate representation of the client’s current state.
We have included the drug andfrequency of use, criminal behaviour, social function, andhealth rating sections. Because alcohol is not illegal, we have not included it in our data. We have also not included injecting behaviour because we did not consider this relevant to drug classification, our main focus. Some client files did not have TOP forms, so these individuals are not included. Some files had more than one TOP form – in these cases we used the least recent form, which was generally the form from the initial appointment.
Our website contains five main sections; these are:
- The Drug Classification System.
- Drugs and Associated Criminal Behaviour.
- Drugs and Associated Physical Health Problems.
- Drugs and Associated Mental Health Problems.
- Drugs and Associated Social function.
We believe that this type of research is important, particularly in the context of the UK government’s pastdisregardfor evidence-based independent advice on the drug classification system, including the decriminalisation of cannabis and the possible reclassification of ecstasy. It is important that this debate is kept open and that independent researchers are able to continue to present evidence about illicit and legal drugs.
The Drug Classification System
To pass comment on whether our drug classification system works,we must first understand how it works. The origin of the current system stretches back to 1920 and the implementation of the Dangerous Drugs Act1. This act continuously developed until 1971 and the implementation of the Misuse of Drugs Act1which introduced the class system that is seen today. Before the introduction of the class system, all drug offences were “treated with the same degree of seriousness”, so at the time possession of cannabis was viewed akin to possession of heroin1. This act introduced the three-tier class system for all drugs with each being given a rating of: Class A, Class B or Class C. These classes are arranged in such a way to “reflect their relative harms and the maximum penalties which offences relating to their cultivation, possession and supply attract. With respect to that statement from the Home Office, it is safe to assume that Class A drugs are viewed as more dangerous than Class B drugs by the UK government2. As we delve deeper into the other sections of this report it should become clear if this is the case or if the system needs to be revaluated.
The current legal penalties associated with the drug classification system.
This system has very rarely been changed, with the most recent changes coming in 2004 and 2009 changing Cannabis to a class C drug and then back to a class B drug respectively. Since 1971 the world of drugs has undoubtedly changed, new drugs have been synthesised, new research has been done and drugs have become stronger, particularly cannabis whose national THC percentage average in 1978 was 1.47% but was 5.81%3in 2008. Whilst new drugs have been added to the classification system – including past“legal highs” such as mephedrone and LSA – for all the changes that have occurred in the drugs world the classification system has remained largely the same.
The 1971 Misuse of Drugs act not only implemented the drug classification system but also founded the advisory council on the misuse of drugs1. This council is an independent group of public health experts from a variety of backgrounds. The 1971 Act states “the advisory council should give advice on measures (whether or not involving alteration of the law) which in the opinion of the Council ought to be taken for preventing the misuse of such drugs or dealing with social problems connected with their misuse”1. Ministers are required to consult with this body before any decisions are made regarding the classification or reclassification of drugs. The problem therein lies that any proposed changes require a majority approval in the House of Commons as well as the House of Lords. For example the independent group voted in favour of again reclassifying cannabis as a class C drug however this fell on deaf ears and it was not brought throughparliament2. This led to a large public outcry leaving many wondering why the taxpayer is funding a group of public health experts whose input was ignored.
There have been numerous independent reviews by various organisations criticising the drug classification system over the years. In 2000, the police foundation played a major role in having ecstasy reclassified from a class A to class B controlled substance2. Their report looked into the developments in medical knowledge surrounding amphetamines and presented the government with the facts. Since that first ground-breaking review there have been many others like it but some did not see the light of day, fortunately under the freedom of information act such reports have been released. Among these reports is the 2006 “Review of the UK’s Drugs Classification System – A Public Consultation” which concluded that the current drug classification system was inadequate and needed to be reevaluated as it was no longer “fit for purpose”. We shall be examining the data from our TOP forms as well as reviewing past literature to determine whether or not the current system is still fit for purpose.
Drugs and Criminality
“ If we want to help sustainable economic development in the drug-ridden states such as Colombia and Afghanistan, we should almost certainly liberalise drug use in our societies, combating abuse via education, not prohibition, rather than launching unwinnable ‘wars on drugs’, which simply criminalise whole societies.”[1]
In 2003, Lord Adair Turner of the former Financial Services Authority spoke of how domestic policy can have beneficial effects for foreign countries where the production and consumption of narcotics is commonplace. Far from the poppy fields of Afghanistan or thecocafarms of South America, the United Kingdom has a far different relationship with drugs, but his words still have relevance. For years we have tried to extinguish the presence of ‘harmful’ drugs in society, but with usage ever evolving, and still commonplace today, it may be time to change our attitudes and change our policies.
To question our relationship with illegal drug use here in the UK, it is important to first explore the relationship between drugs and crime. Are our current drug penalties concordant with how harmful they are? Are drugs contributing to considerable criminal activity out-with possession and supply? Could we stand to gain from decriminalizing some drugs?
Since the Misuse of Drugs Act was implemented in 1971, illegal substances have been classified into three tiers: Class A, Class B and Class C[2]. Drug offences are divided into “possession” and “supply and production”, and carry different maximum penalties to reflect their perceived severity. For possession, the penalty can be an unlimited fine, or up to 2, 5, or 7 years in prison for Classes C, B, and A respectively. In the case of supply and production, the penalty can be up to 14 years in prison for Classes B and C, and up to life imprisonment for Class A. The validity of the classification system has been questioned in recent years, and the relationship between penalty and harmfulness of the drug in question has been disputed. Nutt et al[3]highlighted in 2009 that if relative harmfulness was the main deciding factor in drug classification, then alcohol and tobacco should be placed in a higher drug class than cannabis and ecstasy.
Nutt’s list depicting the harm caused by legal and illegal drugs.
It is undeniable, however, that drugs and crime have an almost symbiotic relationship. Goldstein[4]stated that drug related crime could be divided into three areas – “economic-compulsive” crime that results from a need to fund drug purchases, for example theft and burglary; “psycho-pharmacological” crime that arises from the action of the drug, such as violent responses or affected decision making; and “systemic” crime, a feature of the drug trade, for instance where legal enforcement is not utilized. Different drugs have different relationships with crime – for example heroin use is associated with a high rate of economic-compulsive crime[5], and our own research found that the crack-cocaine users investigated all had a history of violent crime. This is an important consideration for future drug policy. For instance, does ecstasy belong in the same class as crack-cocaine when it is less harmful pharmacologicallyandless likely to predispose users to violent behaviour?
Decriminalization and legalization of certain illicit substances is an issue that has been subject to increasing debate over recent years, particularly in the case of cannabis. Several US states have made the move to legalize in the past two years, and Colorado, the first to do so, has been benefiting from millions of dollars from tax revenue each month[6]. As well as a potential source of income, the decriminalization of certain substances could alleviate strain on government spending. The average cost of housing a prisoner in the UK is around £2897 a month[7], and as of June 2013 there were over 10,000 people serving drug-related prison sentences in England and Wales alone[8]– the penalties associated with illicit drugs come at an undeniable cost to the taxpayer. That considered, a submission by the UK Drug Policy Commission[9]highlighted that although 35,471 people had been sentenced for a drug offence in 2009, almost 3 million people had used a controlled drug in the same year, mainly cannabis. If one can extrapolate from that a ratio of 1 conviction per 84.6 offences, the question can be raised of how worthwhile the allocation of law enforcement and criminal justice system resources are in policing minor offences such as cannabis possession.
Although it is indisputable that drug use can have negative consequences on the individual, it can be argued the current penalties for drug use are unrepresentative of their nature, and the legal framework around drug use ought to be restructured. The reclassification of certain substances could facilitate more appropriate penalties for drug users. Decriminalization of certain substances, such as cannabis, could reduce government spending on law enforcement and criminal justice, and full legalization could also provide income in tax revenue. These would be huge steps to make considering current attitudes towards drug use in the United Kingdom, but if the situation is to be improved it is important that these nuanced issues are given open forum.
Drugs and Psychological Health
Throughout recent history, the potential effects on mental health of recreational drugs have been some of the most widely considered. This section will look at the evidence for drugs having adverse effects on psychological health and will examine TOP forms to look at the self-grading of psychological health by people who have been referred to a drugs support clinic in the Craigmillar area of Edinburgh. The drugs referred to in this section will be cannabis, heroin, crack cocaine, cocaine, amphetamines and benzodiazepines.
One of the most common drugs in the UK is cannabis, and as such it has been one of the most investigated drugs. Cannabis is also one of the more socially acceptable illicit drugs and is rated as Class B. Studies into the effects of cannabis on psychological well-being have shown a variety of results. A systematic review of longitudinal, general population studies among young people suggests that, although cannabis is associated with poorer psychological health, this can be explained by non-causal mechanisms[1]. One study suggested that occasional adolescent cannabis users are more psychologically adjusted than those that have never tried it, although this effect was reversed in frequent cannabis users. These results can be explained by non-causal factors, such as social factors[2]. This study is from 1990 and societal attitudes and behaviours around drugs may have changed in the past 25 years. It was also based in the US, which may have a different attitude to cannabis than the UK.
In contrast to the above, some studies have concluded that cannabis use in adolescence can have negative impacts on psychological health in future life. A systematic review in 2007[3], which checked for confounding in all of the papers it included, found that there was a significant increase in psychotic symptoms in 40% of cannabis users, with a dose-response effect meaning that the most frequent users are up to 200% more likely to develop psychotic symptoms. A large scale recent review like this can be seen to be reliable in its findings, and we can conclude that there is an association between psychosis and cannabis use.
A systematic review[1]found a definite relationship between cocaine use in adolescence and poorer psychological health (including psychotic symptoms and attempted self-harm). Other drugs have psychological effects as well – studies have found that heroin addicts are more likely to suffer from depression[4]and other mental health problems, although it is hard to know whether heroin is causative of these problems or merely a symptom, or if the link is due to confounding. According to a WHO report[5], chronic heroin use carries the risk of experiencing anorexia, lethargy, mood swings and depression related to acute drug effects. This report claims that there is no direct link between opiates and chronic psychiatric
Another study in America[6]investigated the cumulative effects of drug use, suggesting that there is a pattern with people taking progressively more damaging drugs (crack cocaine being the worst). This study found that those taking more drugs (up to crack cocaine) were around 8 times more likely to have seen a doctor about a psychological problem in the past year than those that take no drugs, along with a significant difference between cocaine users and crack users.
When we analysed the TOP forms, it was hard to come to definitive conclusions due to the poor quality of the data. The small data set, particularly for cocaine, crack cocaine and amphetamines, meant there were few statistically significant results. The mean psychological health ratings for each of the drugs taken as the only drug were: Heroin – 7.24 (n=25), Crack – 4 (n=3), Cocaine – 6 (n=2), Amphetamines – 7 (n=1), Cannabis – 9.94 (n=18), Benzodiazepines – 15 (n=2). In terms of cumulative effects of drugs, the means were: One drug – 8.2 (n=51), two drugs – 6.56 (n=28), three drugs – 6.98 (n=15), four drugs – 5 (n=2). The figures for those taking any combination of drugs including a specific drugs were: any heroin use – 5.9 (n=67), any crack use – 3.15 (n=11), any cocaine use – 8.6 (n=6), any amphetamine use – 7.43 (n=8), any cannabis use – 8 (n=42), any benzodiazepine use – 7.28 (n=23). T tests were conducted on the data with a significance level of p=0.05. These tests did not find any significant findings except for the difference between any crack and any cannabis use (t=0.011), any heroin use (t=0.03) and any benzodiazepine use (t=0.039). No T tests were conducted on any cocaine use and any amphetamine use as these data sets were too small.
From the statistics, it is possible to conclude that the only drug that has a significant effect on psychological health is crack cocaine. However, looking at the data, it does appear that there are also differences in, say, heroin vs cannabis use alone (means of 7.24 vs 9.94 respectively). This suggests that if our sample size was bigger, we may have been able to draw more significant conclusions. This also reflects the literature on the subject, which suggests that cannabis may have little psychological health effect, whereas heroin and crack have more effect.