Keep it legal?

Professor David Nutt asks whether it is time to rethink policies on alcohol and other drugs

If you ask most people “what is a drug?” it is likely they will reply with examples like cannabis or heroin or cocaine. Rarely will they say alcohol or tobacco or coffee. Why is this? Well, one reason is that the concept of a drug has become deeply entangled with the concept of illegality. If it’s legal then it can’t be a drug.

To some extent the drivers of our beliefs are embedded in our own experience. The drugs that are not considered drugs, such as alcohol, tobacco and caffeine, are legal and widely used, so most people have either personal or family experience of their use. The most popular “illegal” drug is cannabis with up to 10% of the population having used it, a much lower percentage than the legal drugs, with alcohol being used by up to 80% of adults. Perhaps familiarity breeds contempt? Or do we turn a blind eye to alcohol because we enjoy its effects?

The truth is more complex, representing a mixture of historical misrepresentation, political machinations and moral perversity. On top of all this there is the awful failure of drug policies to do what they were supposed to do—reduce harm—and in many cases they have undoubtedly caused more harm than good.

Over the past decade a number of international expert groups have reviewed the harms of many commonly used drugs and all have come to the same conclusion—in western societies alcohol is the most harmful drug overall. The first of these studies is shown in the figure below. The overall height of each bar represents the harm that each drug produces. Alcohol scores highest largely because of the size of the red bar. This represents the relative harms that each drug does to other people, ie society. The size of each blue bar represents relative harms of each drug to the user. So, alcohol isn’t the most harmful drug to users—heroin, crack cocaine and methamphetamine score higher than alcohol. But because alcohol is so widely used the societal impact pushes it to the top of the harms list. There can be very few families in the UK that have not had a member harmed by alcohol—either from abusing it themselves or being harmed by someone under the influence, such as a drunk driver. Also, the huge health care costs of alcohol fall on all taxpayers.

It is obvious from the position of drugs in the chart that there is no relationship between the harms of drugs and whether they are legal or not. Why is this and does it matter? Drug laws have emerged over the past century in response to concerns about harms, with the most obvious being the banning of alcohol in the USA in the early 1920s due to pressure from religious temperance movements. This turned out to be a disastrous move as it led to the rise of organised crime and the corruption of local policemen by the underground speakeasies. To counteract this abrupt rise in criminality a new un-corruptible squad was created: The Untouchables. When in 1933 the Senate voted to repeal alcohol prohibition, this army of over 30,000 men was faced with redundancy, so their leader Harry Anslinger came up with a solution—find another enemy. He chose to target cannabis, referring to it as marijuana to associate it with Mexicans, and so the war on drugs started, waged by the newly created Federal Bureau of Narcotics, predecessor of today’s Drug Enforcement Administration, or DEA. It continues to this day in the USA and most of the rest of the world including the UK. Even in the USA cannabis is still illegal under Federal law though legal for recreational as well as medical use in many US States.

Although the war on drugs was initiated to maintain employment in the DEA, it then got a massive expansion under the Nixon presidency for political reasons—it was a covert way of targeting the antiwar movement and the black community. The US being highly influential in both the UN and the WHO, the international community, including the UK, fell into line. And, once a drug has been made illegal, undoing this decision has proved almost impossible. In fact, no drug made illegal under the UN Conventions has ever had that status undone.

You might say does it matter? Banning a substance can’t really do any extra harm can it? And if they were made legal wouldn’t use then grow? The first point is easily refuted using alcohol prohibition as an example—banning alcohol in the US led to much greater, albeit different, harms. Hence it was repealed. Strangely, that lesson of history has yet to be learned in relation to other drugs. Politicians still claim that prohibition of cannabis is necessary to protect the public, with recent calls from the Home Secretary to make it a Class A drug. In truth, cannabis prohibition in the UK has failed spectacularly, leading to the rise of more harmful versions such as skunk and spice. Over 20 other countries have now made recreational cannabis legal and have not seen major problems such as increased use or harms. What they have seen is useful tax revenue and much easier access to medical cannabis for patients.

As well as the obvious health harm costs from the failures of drug policy, there are significant hidden costs such as the vast expense of policing these policies and the international damage they cause. On top of this there is a major hidden cost of prohibition that is usually overlooked: the lost opportunities for clinical treatment and research with banned drugs. Psychedelics such as LSD and psilocybin were revolutionising the treatment of mood disorders and addiction until recreational use led to their being banned. This happened more than 50 years ago and has still not been rescinded. MDMA, aka ecstasy, was being widely used for mood and stress disorders such as PTSD before it was banned 30 years ago. Medical cannabis was legal in the UK for over a century until being banned for racial and political reasons in 1971 and, though this was overturned in 2018, there are almost no prescriptions on the NHS. Many other illegal drugs—some cathinones, amphetamines, and ketamine analogues—also have considerable untapped potential as medicines which will never be realised until the bans are overturned.

The above should make us all take stock of our attitudes to drugs and drug policy. We need to establish what we are trying to achieve and then develop policies that maximise these goals. The starting point, I think, should be to agree on a what is the purpose of the policy.

For me and many others it will be to reduce the overall harms of drug use while, where possible, taking into account benefits as well. Some of you might want to take a moral position—stick with the current legal status quo on the principle that the law is sacrosanct. Others might rely on a religious perspective and ban alcohol along with cannabis, as under Islam.

Even if we can cope with the paradox of the most harmful drug, alcohol, being legal while other less harmful ones such as cannabis and magic mushrooms are illegal, there is still the issue of how we can reduce alcohol harms. History tells us that prohibition isn’t the answer, so what is? Taxation can reduce intake as has been shown by the Scottish minimum unit price initiative. One reason for the massive increase in alcohol harms over the past 50 years is that in real terms the cost of alcohol has fallen to third of what it was in the 1950s.

Another approach is to find less harmful alternatives to alcohol. This is something I have been developing with new botanical functional herbal drinks. This is designed to replicate the pro-sociability effects of alcohol by targeting the main calming neurotransmitter in the brain—the gamma-aminobutyric acid (GABA) system—without the other unwanted effects of alcohol that lead to dependence and hangover. In principle, safer alternatives to many other recreational drugs could be developed that, if they were made available in regulated outlets such as pharmacies, could reduce drug harms overall. Whether the current political parties would allow such a rational development is an open question—one which I am sure your organisation will have opinions on!

David Nutt is Professor of Neuropsychopharmacology at Imperial College, London and the founder of the charity Drug Science. He set up the company GABA Labs to develop less harmful alternatives to alcohol—find out more here: https://sentiaspirits.com. He has written many books, three of which are relevant to this article: Drink?, Cannabis (Seeing Through the Smoke), and Drugs: Without the Hot Air.