Rapid Responses to:

EDITORIALS: Michael Gossop Classification of illegal and harmful drugs BMJ 2006; 333: 272-273 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Alcohol could be substituted with safer alternatives such as benzodiazepines or marijuana

Bruce G Charlton   (4 August 2006)

Benzodiazepines lead to mistakes and a lack of balance in experts

Phil Harrison-Read   (17 September 2006)

Alcohol could be substituted with safer alternatives such as benzodiazepines or marijuana 4 August 2006
Bruce G Charlton, Reader in Evolutionary Psychiatry Newcastle University, NE1 7RU, UK Send response to journal: Re: Alcohol could be substituted with safer alternatives such as benzodiazepines or marijuana	It is pleasing to see some rationality creeping into the debate on the escalating alcohol problem [1]. The UK now combines internationally high rates of alcohol consumption with the binge drinking patterns typical of high latitude countries [2]. But it seems unlikely that traditional means of controlling alcohol consumption by abolition, raising price and restricting access will be viable in modern societies [2]. A radical new approach is required. Alcohol users should be regarded as rational consumers who are drinking in order to attain specific psychological effects - and who would substitute alcohol for safer alternative drugs if these were legal, available and affordable [3, 4]. For example, benzodiazepines are a safer alternative for achieving the relaxed sociability of slow, low-dose alcohol consumption, while marijuana is a safer and less violence-inducing intoxicant than binge drinking [4]. Preliminary economic analysis suggests that consumers will indeed make these safer substitutions - when the choices are available [5]. All that is needed is for public policy to swing away from being prohibition- oriented to being choice-oriented. 1. Gossop M. Classification of illegal and harmful drugs BMJ 2006; 333: 272-273 2. The Economist. Drinking culture: in a pickle – Britons drink southern European quantities in northern European style. The Economist March 18 2004. 3. Nutt DJ. Alcohol alternatives - a goal for psychopharmacology? J Psychopharmacol. 2006; 20: 318-20. 4. Charlton BG. Diazepam with your dinner, Sir? The lifestyle drug- substitution strategy: a radical alcohol policy. QJM 2005 98: 457-459. 5. Chaloupka FJ, Laixuthai A. Do youths substitute alcohol and marijuana? Some econometric evidence. Eastern Economic Journal. 1997; 23: 253-276 Competing interests: None declared
Benzodiazepines lead to mistakes and a lack of balance in experts 17 September 2006
Phil Harrison-Read, Consultant Psychiatrist Department of Psychiatry, Royal Free Hospital, Pond Street, London NW3 2QG Send response to journal: Re: Benzodiazepines lead to mistakes and a lack of balance in experts	Editor - "Valium" is an obsolete proprietary name for the prototypal benzodiazepine drug, diazepam. The word "valium" with a small 'v' is often loosely used to mean any benzodiazepine or other mildly sedating pharmaceutical anxiolytic which is typically (over)-prescribed by doctors and has a 'street value' as a drug of misuse and dependency. Misuse of "valium" may often be in the context of enhancing or ameliorating the effects of other more dangerous illegal drugs, thereby resulting in "valium"-type drugs acquiring a probably undeserved reputation for being highly harmful. In Gossop's article(1) about the recent report from the House of Commons Select Committee on Science and Technology concerning the classification of illegal and harmful drugs (2), the erroneous inclusion of "valium" in a Table of harmful 'Controlled Drugs' is apparently intended as a short-hand for benzodiazepines (BDZs) as a class. However the mistake may also be indicative of inconsistent but mainly dismissive attitudes regarding these drugs by those acting in an advisory capacity to governmental bodies. BDZs are 'Class C' 'Controlled Drugs' in the present classification of illegal and harmful drugs arising from the Misuse of Drugs Act 1971 (MDAct), and it is therefore illegal to possess or supply them except under specific circumstances. However with the exception of temazepam, which alone of BDZs is subject to a requirement of 'safe custody' under Schedule 3 of the Misuse of Drugs Regulations 2001, and is identified as a 'Controlled Drug' in the British National Formulary (BNF), all the other BDZs listed in the BNF fall within Schedule 4 of the Regulations and are therefore not subject to special prescribing or safe custody requirements. Despite being pharmacologically similar to temazepam, these other BDZs are not even labelled as 'Controlled Drugs' in the BNF, an indication perhaps that they are considered to be relatively innocuous. Despite once being valued as a class of psychotropic drugs renowned for having a remarkably high "therapeutic index" when taken on their own, BDZs are now ranked ahead of amphetamines, tobacco, cannabis, LSD and ecstasy, and only just behind alcohol in a "new league table" of harm devised by the Advisory Council on the Misuse of Drugs (ACMD). This league table only appears in an appendix to the electronic version of the parliamentary report (2) and is not referred to in the article by Gossop(1). However it is mentioned in in a BMJ News item published in the same issue of the BMJ (3). The league table, dubbed "a rational scale for assessing the risks of drugs of potential misuse", is the ACMD's preliminary contribution towards an alternative to the MDAct's current 'A,B,C' classification, and is in line with the Parliamentary Committee's views that the harms of drugs of misuse should be considered as independently as possible from legal considerations regarding the drugs' supply and possession. The main value of this approach is of course to allow 'legal' substances such as alcohol and tobacco to be placed on a list of harmful substances of misuse, and relatively high up at that. In order to understand how the apparently relatively innocuous BDZs could be ranked by the ACMD above tobacco and only just below alcohol in a league table of harm caused by misused drugs, it has to be appreciated that the list represents the systematically assembled views of two groups of "independent experts" (psychiatrists and other professional specialists in 'addiction') using a rating scale which considers nine parameters in three dimensions of harmfulness: physical harm, psychological (dependence- inducing) harm, and social harm. Evidence based on opinion, especially in an area of enquiry dominated by political and other non-clinical agendas, must be treated cautiously, and even a cursory examination from a clinical perspective casts serious doubt on the quality of the ACMD's evidence with respect to BDZs. On the ratings of 'physical harm', BDZs scored above both alcohol and tobacco. This is simply not credible given the known clinical pharmacology of BDZs(4), and unfortunately serves to undermine the ACMD's worthy attempt to focus attention on the official neglect of harms caused by alcohol and tobacco. The ACMD's consideration of 'psychological harm' from drugs of misuse focuses exclusively on drug dependence rather than on other psychological effects. This is an extraordinary limitation given that the drugs under consideration have many other complex psychotropic effects. On this parameter, BDZs are rated as more harmful than amphetamine, cannabis, LSD and ecstasy, a finding which again does not square with clinical experience or with common sense. Most if not all 'jobbing' psychiatrists such as myself would be considerably less concerned by their schizophrenic patients misusing BDZs than the psychotomimetic drugs cannabis and ecstasy, and if obliged to consume either a tablet of diazepam or a dose of LSD, even the most psychologically-robust of the ACMD's experts might have serious qualms about opting for the latter in preference to the former! The credibility of the ACMD's view on benzodiazepine dependence is further put into question by their considering the occurrence of 'withdrawal symptoms' in subjects who believe that their BDZs are being reduced or stopped when in fact they are not. These so-called 'pseudo- withdrawal' or 'nocebo responses'(5)(6) are likely to be a reflection of the personality of individuals who are susceptible to unusual experiences of this sort and who coincidentally are more likely to become dependent on BDZs, rather than a harmful property of BDZs per se. Of course BDZs do have many harmful effects, some well-documented, others less well-known or understood. For example, the small minority of subjects who have intractable difficulties in withdrawing from long-term use of even small therapeutic doses of BDZs may show dramatically altered responses to challenge with the BDZ receptor antagonist flumazenil, possibly an indication of BDZ-induced changes in the brain GABA-BDZ receptor complex(7). Although the effects of BDZs are still inadequately researched, particularly individual differences in responses to BDZs, the pervasive negative attitude towards BDZs in some circles seems to have effectively extinguished interest in carrying out controlled studies of the intricate effects of these substances. However,even without new research, the ACMD's placing of BDZs between alcohol and tobacco in a league table of harm may yet need to be revised. (1) Gossop M. Classification of illegal and harmful drugs. BMJ 2006; 333:272-273 (2) House of Commons Science and Technology Select Committee, 2006. Drug classification: making a hash of it? 5th report of session 2005-6, HC1031; 31st July 2006; (www.publications.parliament.uk/pa/cm/cmsctech.htm)(accessed 11th Sept.2006) (3) O'Dowd A. News: tobacco and alcohol should be classed as dangerous drugs. BMJ 2006; 333:275 (4) Cooper SK. Anxiolytics, sedatives and hypnotics. In: King DJ, ed. "Seminars in Clinical Psychopharmacology". Second edition. Gaskell, London; 2004: 141-177 (5) Tyrer P, Owen R, Dawling S. Gradual withdrawal of diazepam after long-term therapy. Lancet 1983; i: 1402-1406 (6) Harrison-Read P, Tyrer P. The clinical principles underlying drug treatment in psychiatric practice. In: King DJ, ed. "Seminars in Clinical Psychopharmacology". Second edition. Gaskell, London; 2004: 92-138 (7) Harrison-Read PE, Tyrer P, Lawson C et al. Flumazenil- precipitated panic and dysphoria in patients dependent on benzodiazepines: a possible aid to abstinence. Journal of Psychopharmacology 1996; 10:89-97 Competing interests: None declared