- Margaret McCartney, general practitioner, Glasgow
The drum roll that Channel 4 sounded for Drugs Live: The Ecstasy Trial, its “ecstasy on television trial,” meant that even before it was screened (10 pm, 26 and 27 September 2012) the camps for and against had formed in the printed media. Channel 4 said that it was the “first experiment of its kind” to use functional magnetic resonance imaging (fMRI) to examine the effects of the illegal recreational drug MDMA (ecstasy) on healthy volunteers.1 David Nutt, famously sacked from being a senior drugs adviser to the government over his stance on drug taking and risk, told the Observer that the project had two purposes: firstly, to “show the whole process—from design to analysis—of a scientific experiment being performed”; and, secondly, to perform the imaging.2 The Medical Research Council had turned down the request to fund the study. Nutt said that the study had scored highly but didn’t fit with the council’s portfolio of research, so Channel 4 stumped up the cash. Nutt said that he should “be commended for finding a way to do quality science.” But was it quality science?
There are many concerns that the public is not properly informed about clinical trials and yet there is a clear need to reduce uncertainties about treatment. Throughout the programme, we were reminded that MDMA was controversial and that half a million people use it in the United Kingdom every year, and no one knows how it works or what therapeutic benefit it might have. Drugs Live was filmed with a studio audience, who stood to applaud, and this was broadcast live. Footage of the participants taking either MDMA or placebo was prerecorded. This was not a random selection of people; they included the novelist Lionel Shriver and a former SAS soldier.
A description of how and why the trial had been designed was lacking. The key to quality research is first to review current knowledge systematically, and if the intent of Drugs Live was to show the public good science then this should have been demonstrated. The need to use a placebo was not explained. In fact, the actor Keith Allen, another study participant, asked whether the effects that another participant described could have been because of placebo—the only person on the show to do so.
The fMRI results were explained by the presenter Jon Snow and Nutt, in conjunction with a giant plastic brain with parts that lit up to show when they were being “activated.” The results from psychology experiments during and after the fMRI scanning were presented with unclear graphs and no sense of statistical significance or explanations of how the data would then be assessed. It fell to Evan Harris, the Liberal Democrat politician and another study participant, to explain that data should be written up, statistically analysed, peer reviewed, and published before conclusions could be drawn. Unfortunately, his explanations were given little priority in relation to the competition.
Viewers’ tweets were read out, giving their opinions about taking ecstasy. Audience members explained their good and bad experiences of the drug. One trial participant thought that she had been able to deal with post-traumatic stress because of the MDMA she took in the trial. Video footage showed an American woman who thought that using ecstasy in conjunction with psychotherapy had helped her deal with post-traumatic stress disorder, and she told the cameras this because she wanted to “open minds” and “help lots of people.”
Unusual camera angles and different screen colours were used often, presumably to hold viewers’ attention and perhaps to also attempt to simulate effects of being on the drugs, but they were a distraction. Some scientists argued that MDMA was an unpredictable and risky drug that was unlikely to be clinically useful; Nutt and his colleague Val Curran said the opposite. It was presented as a debate; yet it was unclear what was broadly agreed and what was controversial. Snow told us that the results were amazing and incredible; another presenter, Christian Jessen, collected vox pops from the studio audience and gave viewers advice on how to take ecstasy if they were determined to do so.
We rightly talk about drug companies having undue influence over clinical trials, their results, and their presentation—but what about television companies? Channel 4’s need to create the programme drove its description of the trial and presentation of the data. Had the methods and results been ascribed more importance, it would have helped the viewer appreciate the importance of randomised controlled trials as opposed to the power of anecdote. The live format promoted sharing of opinions but the hierarchy of evidence was not explained or investigated. Originally the programme makers wanted to show the taking of ecstasy live, but a condition of trial approval was that it was not live. Making the remainder of the programme live seemed unnecessary.
Crucially, Drugs Live failed to distinguish clearly between the issues surrounding illegal use of recreational drugs and the vast difference with the controlled clinical experiment being run. Viewers calling in often discussed personal experiences after illegal use of ecstasy. Many drugs can be misused but can also be prescribed and have clinical usefulness. There should be no difference if MDMA is found to be effective in some conditions, in which case there should be no stigma about using it. It requires a Home Office licence to study MDMA, and Nutt, explaining the current research situation to the Observer, said that drug companies were concerned about the potential for negative publicity should they research MDMA. What MDMA could be effective for, however, has not been shown, and although the presenters described the fMRI findings of the effects of MDMA as “groundbreaking,” they neglected to tell us what this means for future research—that is, statistics, more trials, more tests, and more questions. The relation between the fMRI findings and real life outcomes was not described; in one instance a researcher told a blinded participant that he thought she probably had taken the active drug. Nor was it clear what questions this trial could not answer, including that it could not give reassurance to people thinking about taking, or already taking, MDMA. It’s necessary that the public engage with and understand science, uncertainty, and the need for clinical research, and how science works. But this programme was not an example of how to do so.
Cite this as: BMJ 2012;345:e6621