The Norm Chronicles (15 page)

The Times
reported in 2012 what it called the ‘Scandal of 1m caught in tranquilliser addiction trap’, about ‘the failure of the NHS to provide meaningful support to victims of benzodiazepine addiction, even though they significantly outnumber those hooked on illegal drugs’. Unlike with heroin, there are no hard-hitting public information campaigns about how painkillers screw you up.

Are Prudence, Norm and Kelvin all users? They would disagree, as will readers. They would also differ over the severity of the risks. Which is worse: booze, Kelvin’s painkillers or cocaine? Does Pru’s stimulant of choice (tea, but not Fair-Trade tea – so some will say that her tea addiction is socially harmful) belong on the same page as Norm’s experiment with E, or is Ecstasy little more dangerous than a cuppa for many self-described recreational users who successfully hold down a job and relationship?

Knowledge changes, beliefs vary, attitudes are all over the shop and numbers are only part of it. People’s sense of harm is and always was plainly bound up with personal experience, anecdote, moral values and personal preference – what’s your poison? – as well as social norms, norms among friends, among their income, ethnic and age groups, or
in society as a whole, norms that are sometimes freely chosen and sometimes not: whether, for example, they turn into social pressures to conform, with a drink, or a tab.

Often the illicit drug-user’s first line of defence is to say that attitudes to alcohol prove there’s no consistent scale of harm, only shades of hypocrisy. In the decades since governments began to talk more about the dangers of drug use, two of the most potentially dangerous and addictive drugs – tobacco and alcohol – remained legal, even as drinking in the UK rose sharply in the 1980s and early 1990s. As a result, it is said: ‘A whole generation learned to ridicule and ignore all governmental advice on the subject.’
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Others talk – not always in ironic tones – about ‘respectable drug addiction’ – middle-class use of the opiate-based Codeine to help with sleeplessness, for example. What could be less sinister than wanting a good night’s sleep? But Codeine dependency can be ugly and dangerous too. Rules and attitudes said to be linked in large part to risk and harm have a fickle relationship with it.

Even so, and despite being keen on data, we would argue that little of this mess is intrinsically wrong or irrational, although it may not always be honest or self-aware. It is simply that danger is only one part of a hideously complicated conversation. How do we describe the risks of drug use when they are part and parcel of what we value in life? Because this is a problem of weighing both personal harm and social harm, harm to a way of life, where sometimes that way of life is threatened by drugs – by the crime they bring – but sometimes it may depend on them, like a few pints down the pub at Sunday lunch, half an E at a club or a cigar at the races. Add to that a fierce disagreement about how best to minimise the harm, by prohibition, decriminalisation or a war on drugs, and you have a recipe for muddle.

Questions of value give philosophers headaches. The point of saying all this is that risk can also fall – and should – into the same category of philosophy, one of competing values and traditions at least as important as the power of the data. So heated is the argument about illicit drug use that it is almost surprising anyone should think data could settle it.

Perhaps the acid test (no pun intended) of the relevance of the data to this whirl or beliefs and emotions is how you react to Norm. What
did you think when he tried to skip over all the values business with a purely data-driven approach to excitement, illegal or not? Is he the only sensible person on the planet? Prudence doesn’t think so. Or is his kind of logic, in this instance, insane?

The anthropologist Mary Douglas argued that the assertion of risk – ‘don’t do that, it’s dangerous’ – is often sly social control. If behaviour offends us, for whatever reason, we warn that bad things will happen and we call the behaviour ‘risky’. In her fieldwork she found tribal women who’d been told that if they were unfaithful they ran a greater risk of miscarriage, a risk presented to them as a fact of nature a bit like the need to take care with a sharp knife. The supposed biological risks of the behaviour were clearly a fiction; the true purpose, the social purpose, of warning about the risk of infidelity was evident: to control the women’s behaviour. Early in her career Douglas thought this the kind of thing only primitives do, since superseded by science. Later she argued that we all do it, in all cultures and all ages.

But wherever one person seeks control, another kicks back. Hunter S. Thompson couldn’t consume enough illicit drugs, more determined to stuff them down because others wanted to stop him. His accounts of his drug binges read like a knock-down fight with majority opinion. He describes his ‘twisted’ – a good word – trip to Vegas as fulfilment of the American Dream. Some dream.

Thompson was not your everyday risk-taker. But was he unusual when he suggested that the best way to resist control is to assert control of your own, even unto being out of it? Transgression is partly what risk-taking is about, at least for some. Stepping over a boundary can be a thrill in itself.

So in front of any statistic about the quantified level of danger we need a flexible sign, positive or negative for different readers, depending on what they approve of, while also recognising that the value they put on any risk isn’t only up to them. Their behaviour affects others. So calculating the dangers of drugs is both a personal judgement and a blazing social row replete with wider values and preferences at least as much as it is a statistical, evidence-based exercise.

Mind you, once sociology, anthropology, psychology and the rest
have said all this, you sure feel the need for some numbers – if not to make policy, then at least to help make up your own mind. What are they?

Concern about the addictive properties of opiates and cocaine in the early 20th century led to criminalisation for misuse. Criminalisation makes it hard to estimate the level of harm from drugs, because you first need to know who uses them. If admitting this makes you a criminal, you might keep quiet.

So the British Crime Survey (BCS) guarantees anonymity when it asks about the use of illegal drugs.
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Responses are scaled up to the adult (ages 16–59) population of England and Wales, of whom around 1 in 3 are estimated to have used illegal drugs in their lifetime, around 9 per cent in the past year.

About 3 per cent, a million people, had used a Class-A drug, such as heroin, morphine, metamphetamine, cocaine or crack cocaine, Ecstasy (MDMA) or LSD. Among young people aged 16 to 24, around 20 per cent had used illicit drugs in the last year: 17 per cent used cannabis, 4.4 per cent powder cocaine, and 3.8 per cent Ecstasy – the heroin figure of 0.1 per cent (1 in 1,000) is probably too low, owing to less than full responses from this community. Compared with 15 years previously, in 1996, there had been a fall in overall drug use, with a substantial decline in the figure for cannabis but an increase in cocaine and methadone. Men are about twice as likely to be users as women, and an unsurprising relationship was found between night-club and pub visits and illicit drug use.

What’s so bad about these drugs? They can certainly be dangerous in the wrong hands: a Manchester general practitioner, Harold Shipman, injected over 200 of his patients with lethal doses of diamorphine (heroin) in a murderous career before he was finally caught in 1998 after a clumsy attempt to forge the will of one of his victims. And there have been numerous famous deaths from drug misuse, whether deliberate or not – from Janis Joplin to the Singing Nun.

But working out exactly how many people die this way is tricky: in general, if drugs are mentioned on the death certificate, it means the death is counted in the official data as drug-related, even if the drug was
not the sole cause.
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Altogether there were 1,784 deaths in England and Wales in 2010 from misuse of illegal drugs (i.e., not including alcohol), down slightly from preceding years but double the figure in 1993.

The peak decade for men is the thirties, with 544 deaths. That is around 150 MicroMorts per year, 3 a week, averaged over everyone in that age group, from dopeheads to vicars. Almost exactly half the total deaths (791) were due to heroin or morphine. Cocaine was associated with 144 deaths, amphetamine 56, while those involving Ecstasy fell to only 8 after averaging around 50 a year from 2001 to 2008.

If we use the BCS estimates of the number of users, we get a rough idea of the annual risk, in MicroMorts, for users of different drugs. Averaging out from 2003 to 2007,
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cocaine and crack cocaine were involved in 169 deaths per year, and so an estimated 793,000 users were each exposed to an average of 213 MicroMorts a year, around 4 a week.

Ecstasy’s 541,000 users experienced around 91 MicroMorts a year each, or around 2 a week. Since the 2003 market for Ecstasy has been estimated as 4.6 tonnes,
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this corresponds to around 14 million tablets, or an average of around 26 per user. This translates to roughly 3.5 MicroMorts per tablet.

Cannabis seldom leads directly to death, but its estimated 2.8 million users suffered an average of 16 associated deaths per year, which is 6 MicroMorts a year.

This level of harm is as nothing compared with the average of 766 heroin-related deaths a year, which works out at 19,700 MicroMorts per year – 54 a day – like a 350-mile motor-bike ride every day, or the exposure
every day
to seven times the risk from a year’s worth of cannabis, although this very high figure depends on the BCS underestimate of users, and so is an overestimate of the risk.

But there are many other harms apart from death: for example, it’s been estimated that smokers of cannabis are about 2.6 times more likely to have a psychotic-like experience than non-smokers.
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Heroin injectors may contract HIV or hepatitis from non-sterile needles. They may have abscesses, suffer poisoning from contaminants, apart from the risks of dependency and withdrawal, not forgetting the standard effect of opiates on bowel movement.

John Mortimer (to his father): Did you ever smoke opium?

His father: Certainly not! Gives you constipation. Ever see a portrait of that rogue Coleridge? Green around the gills and a stranger to the lavatory.

[
A Voyage Round my Father
]

Potential effects ripple out from bad guts to violence to felled rainforests and beyond. This is another way of stating the problem about how to make comparisons between harms that matter differently to different people. Is it possible? It’s been tried, let’s put it that way, including an attempt to put a single, summary nastiness number on each drug. A recent study that looked at harms of various drugs, including the legal ones alcohol and tobacco, took in such effects as mortality, damage to physical and mental health, dependency and loss of resources and relationships, as well as harms to society, such as injury to others, crime, environmental damage, family adversities (such as harm to family relationships), international damage (like those rainforests), economic cost and effects on the community.
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. Each drug was scored on each dimension, the different harms weighted according to their judged importance and a total harm score calculated. As with any composite indicator, what goes into the mix and the weight accorded any single factor is arguable.

The resulting ranking put alcohol at the top, with 72, then heroin and crack cocaine, at 55 and 54; tobacco was sixth, at 26, and Ecstasy almost at the bottom of the list with 9, despite being a Class-A drug in the UK. This ranking was controversial, to say the least.

More controversial even than comparing illegal and legal drugs is to compare illegal drugs with wholesome activities. Professor David Nutt, then head of the Advisory Council for the Misuse of Drugs (ACMD), wrote a paper comparing Ecstasy with ‘equasy’, the addiction to horse-riding, claiming that both were voluntary leisure activities for young people of comparable danger.
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He did not remain chairman of the ACMD for long. Not because his numbers were absurd. They weren’t. But risk, to repeat ourselves, is not simply, or even mainly about the threat of harm. His political bosses seem to have decided that comparing horse-riding to drugs wasn’t good politics.

Professor Nutt said the dangers of equasy were revealed to him by the clinical referral of a woman in her early thirties who had suffered permanent brain damage as a result of equasy, leading to severe personality change, anxiety, irritability and impulsive behaviour, bringing bad relationships and an unwanted pregnancy. She lost the ability to experience pleasure and was unlikely ever to work again.

He wrote:

What is equasy? It is an addiction that produces the release of adrenaline and endorphins and which is used by many millions of people in the UK including children and young people. The harmful consequences are well established – about 10 people a year die of it and many more suffer permanent neurological damage as had my patient. It has been estimated that there is a serious adverse event every 350 exposures and these are unpredictable, though more likely in experienced users who take more risks. It is also associated with over 100 road traffic accidents per year … Dependence, as defined by the need to continue to use, has been accepted by the courts in divorce settlements. Based on these harms, it seems likely that the ACMD would recommend control under the Misuse of Drugs Act perhaps as a class A drug given it appears more harmful than ecstasy.
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He concluded that a more rational assessment of relative drug harms was possible, but the drug debate took place without reference to other causes of harm in society, which gave drugs a different, more worrying, status.