Why Being Honest About Drug-Related Risk Might Be the Best Public Health Policy Ever

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Last year over 100,000 people took part in GDS2015 and helped us produce the world’s first safer use limits for an illicit (though increasingly legal) drug — cannabis (http://www.saferuselimits.co) . For many people the notion of describing a spectrum of drug related harm related to the use of an illicit harm is difficult to accommodate. It is the antithesis of many government’s chosen banner of zero tolerance which is totally consistent with the reason they state drugs are illegal — that they are dangerous and bad for your health. Although the FDA may still being plying that message many other parts of the USA are not. So as America enters an age of enlightenment and repeals cannabis drug laws across its vast landscape I thought the idea of safer drug use limits might be of interest (Winstock 2014).

I first had the idea of developing safe drug using limits when I was trainee at the Institute of Psychiatry in the late 1990s. I wanted to develop them as a way of creating a positive dialogue around drug use and encouraging people to reflect on their consumption objectively. My boss at the time told me this was a daft idea and I was strongly advised against pursuing it. Anyway the idea never quite went away because it never seemed that unwise to me. Here’s why.

Guidelines exist for the world’s most dangerous drug, alcohol. These were developed to help people and health care professionals have some idea what different level of drinking might be associated with low risk, moderate risk and high risk of harm. They are based on huge and evolving evidence and although recent epidemiological data has probably underplayed the risks for cancer, dementia and heart disease, properly used (e.g. within the context of brief screening and intervention – see http://www.drinskmeter.com), they can help people reduce their drinking.

The problem is there aren’t really any sensible guidelines on how many drugs you can do in any space of time without running a high risk of ruining your life. In the U.S. as elsewhere, the government line for most drugs is effectively: “Do not take illegal drugs because they are all bad.” Which is helpful when politicians want to skirt questions about drug policy, but entirely redundant for anyone who enjoys taking drugs as part of their life.

Whether its clubbing, f**king, gaming, chilling with friends or just walking, talking and living, zero tolerance drug policies are unhelpful for people who like using drugs but who want to avoid doing themselves too much harm. I guess governments have no choice — they could hardly say a drug is illegal (because it’s very dangerous) and then say ‘look actually if you don’t use too much X too often, not mix it with Y and make sure you don’t play with knives, go scuba diving or drive, then actually the risks of you running into serious harm if you use X is pretty low (not zero — it can never be zero)’.

The reality is that the risks of experiencing harms from using drugs can actually be massively reduced for most people with the right set of advice. Using data collected from GDS2015 we developed the cannabis guidelines as the first of 4 Safer Use Limits (SUL) we plan to produce (others of cocaine, MDMA and ketamine are waiting for funding). The SUL was developed with the aim of raising people’s awareness of the level of risk that different patterns of drug use place them at over the next couple of years. We did this by asking respondents to rate (on a scale of 1 to 10) how the risk of harm from different drugs (including alcohol) is heightened with increasing levels of use. “Risk here refers to the probability, range and severity of harm.

The higher the score the more likely it is for a person to experience any harm, and the higher the score the more problems that person is likely to face and the more severe they are likely to be. We asked 40,000 cannabis users to think about the likelihood of a person experiencing harm over the next 1-2 years. We defined harm as anything that causes a person problems, be it to do with their mental or physical health, their relationships and behaviors, their finances or their ability to work, study, or just do the things in life they want to do.

Are drug users really the best experts?

A reasonable question to ask is how valid are risk estimates based on the votes of a self-selecting group of drug users who surely have cognitive and emotional bias to minimize the risks associated with a consumptive behavior? I don’t know and will leave it to you to decide. But users ratings were remarkably close to those of a small group of experts I asked. The reality is though that the major driver for the approach we took was simply the fact that the ‘people’ who drug users trust most are other drugs users. Simply put I think guidelines on safer use limits voted by those who like to get high, will be less quickly dismissed by other stoners.

I passionately believe that for most people who choose to use drugs and alcohol, they can be source of pleasure that enhances the rich fabric of their lives. While I understand that drug use for some people is unwise (and best avoided) either because of their age, pre-existing health conditions or other vulnerabilities, the decision to use drugs is one that must always be treated with respect. We hope all of our work helps people use drugs more safely, so they remain a source of pleasure not pain to them, those they care for or their communities.

So if you’ve ever used drugs or have thought about drug related harms and pleasures please share your experience and expertise at https://www.globaldrugsurvey.com from mid-November 2016.

Winstock AR Cannabis regulation: the need to develop guidelines on use.BMJ. 2014 Jun 18;348:g3940. doi: 10.1136/bmj.g3940.

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