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Editorial, Journal of Psychopharmacology 20(3) (2006) pp 315-317

A tale of two Es

David Nutt - Psychopharmacology Unit, University of Bristol,
Bristol, UK.

This is the strange tale of two drugs each with a name beginning
with the letter E. One is a dangerous killer that leads to
thousands of deaths every year and the other is ecstasy (MDMA).
The big killer is of course alcohol (ethanol) which, for
historical reasons, is a legal drug in the UK (though not in
many Muslim states). Ecstasy is currently a Class A illegal drug
under the Misuse of Drugs Act that has been in the news recently
because the leader of the Conservative Party (David Cameron)
suggested that as ecstasy was less harmful than other Class A
drugs (such as heroin and cocaine) it might be moved to a lower
class. Within moments of this public statement Cameron was being
castigated by many anti- drugs campaigners and soon the Home
Secretary was pronouncing that as ecstasy unpredictably killed
several people every year he would not countenance its
downgrading. Despite being correct in his logic Cameron was
forced to backtrack on his position because of the present
highly charged public view that politicians must ‘be hard on
drugs’.

But on what evidence do the public and politicians make these
judgements? I and many others have argued previously that the
best way to evaluate the risks and harms of illicit drugs is to
compare them against legal drugs such as alcohol and tobacco. So
what are the relative harms of these two E drugs? (see Table 1).
Ethanol leads to 22 000 premature deaths per year in England
(Rannia, 2003). These are from heart, liver and cancer deaths
plus accidents and suicide, but a sizeable number - of the order
of one a day - die from being poisoned by excessive intake.
Alcohol depresses the respiratory system so death occurs from
loss of oxygen. It also stimulates vomiting but at the same time
blocks the cough reflex, so when vomiting occurs stomach
contents enter the lungs leading to acute respiratory failure.
Sadly the victims of alcohol poisoning are mostly young people -
often under 20 and sometimes as young as 12 - who may never have
been told just how dangerous acute alcohol poisoning is. Often
the death occurs on the occasion of celebrating a birthday or
examination success which makes it even more distressing to the
family and friends, especially if they have bought the drinks.
The public response to these occurrences reveals a state of
public denial that alcohol may be harmful. When someone dies of
alcohol poisoning it is commonplace for the police and family to
suspect that their drinks were ‘spiked’ and set off on a mission
to find the real culprit toxin. The fact that they rarely find
any other drug is usually not reported so the public are left
with the assumption that alcohol was not the real killer.

In a similar way the dangers of alcohol on sexual risk are
widely underestimated. Many women and increasing numbers of men
are raped whilst intoxicated. Often the victim has little memory
of the events and assume that their drinks have been spiked with
one of the so-called ‘date-rape’ drugs. In most cases no drug
other than alcohol is detected. Why? This is because alcohol
itself is a highly effective memory blocking agent. Strangely
there is no education on this risk in pubs or other licensed
premises even though they routinely display warning posters to
women about the need to use licensed taxis or to travel home in
groups to avoid the risks of rape. The fear of date-rape drugs
is so great that some police forces have attempted to make test
kits available to see if drinks have been spiked. It would be
much more effective to provide breathalysers so drinkers could
know how intoxicated they are and so, hopefully, limit further
intake. Bar staff are being encouraged to enforce the practice
of not serving customers who appear drunk - perhaps a breath
test at the bar would help them as well as provide a health
message to the drinker!

These dangers and deaths from alcohol are made more likely by
the arrival of new more palatable forms of alcohol such as
alcopops. These have been designed specifically because they
mask or sweeten the taste of alcohol so removing one of the
reasons why young people used to resist drinking. They also blur
the distinction between lemonades and alcohol, so making
transition to alcohol easier and maybe in some young people even
inadvertent?

Alcohol also kills a large number of innocent individuals
through the increase in road traffic accidents and interpersonal
violence - again figures are not easily available but it will be
tens of thousands per year. Many police are hurt trying to
restrain intoxicated binge drinkers every Friday and Saturday
nights and many non-violent drinkers are assaulted because they
are in proximity to others of more violent alcohol-fuelled
dispositions.

Alcohol also causes dependence and addiction - in about 10% of
users - which often leads to serious damage to family and work
life with huge social and health care costs. It is also a major
contributory factor in suicide.

What of the other E? Ecstasy is the colloquial name for MDMA, a
derivative of the stimulant amphetamine and the subject of this
and the previous volume of the Journal of Psychopharmacology.
MDMA was developed as a potential antidepressant though was
never formally tested for this indication. It has been - and
still is in research centres - used as an aid to psychotherapy
especially for marital therapy with couples where the increase
in empathy it produces can break down barriers that years of
hostility have built up (Grinspoon and Bakalar, 1986). It became
a popular youth drug in the late 1980s along with the ‘rave’
culture where the stimulant properties helped people dance all
night and the empathy experience proved pleasurable and led to a
very much more relaxed and unthreatening event than those when
alcohol was the main drug of choice.

However ecstasy is not a completely safe drug and in the early
rave scene a few deaths occurred as a result of hyperthermia and
dehydration (probably because clubs prevented access to free
water). Public health regulations that ensured free water and
‘chillout’ rooms plus education reduced this problem although
some individuals still died - most notably Leah Betts. It
transpired that her death - and those of some others - was as a
consequence of taking in excess amounts of water without
sweating from dancing so causing water intoxication. In some
people ecstasy can stimulate the release of a hormone, arginine
vasopressin (avp) that retains body water and it is likely that
some people have a genetic predisposition to this effect.

In contrast to alcohol, ecstasy is less toxic in overdose as it
does not cause respiratory depression or block the cough reflex
and it is not addictive. Although it can lead to damage to the
5-HT nerve terminals in the brain in both rats and monkeys, this
is still unproven in humans, though it is a real risk that users
should be aware of. Alcohol is well known to lead to serious
brain damage from both its chemical effects and the fact that
head trauma is such a common consequence of intoxication.

Following the death of Leah Betts her family launched a powerful
and moving campaign against ecstasy which may have reduced use
to some extent. Why have we not seen similar campaigns against
alcohol which kills so many more of our young people? One groups
MADD (Mothers Against Drunk Driving), has argued for more
control of alcohol use and greater punishments for drink-driving
offences but with less obvious public recognition than the Betts
ecstasy campaign. One possible explanation for this imbalance
that has been alleged is that the anti-ecstasy campaign was
supported by groups or individuals with financial interests in
the alcohol industry because they feared a culture shift in
young people away from alcohol to ecstasy and related dance
drugs. Another is that there is little political will, as many
politicians have financial interests in companies that profit
from alcohol. The new open-all-hours drinking legislation that
flies in the face of common sense, proven harm reduction
policies, as well as the Cabinet Office’s own report on alcohol,
may be further evidence of this. Of course the major
contribution that alcohol taxes make to the Exchequer is another
factor to be considered.

Why is ecstasy illegal when alcohol, a considerably more harmful
drug, is not? For alcohol it appears to be because it has always
been so, at least in western society with the exception of the
Prohibition era in the USA. Interestingly ecstasy was only made
illegal in the 1980s purportedly in an attempt to deter use by
young people. This policy clearly didn’t work very well as at
the height of the rave scene up to one million young people were
using each week. In view of this high level of use it may be
that campaigns to reduce ecstasy use might paradoxically
increase harm if they lead to increased use of alcohol.

So was David Cameron right? Both ACPO (the Association of Chief
Police Officers) and the Liberal Democrats have previously
stated that ecstasy should be downgraded. In the most recent
systematic review of the drug laws, the Ruciman committee
applied a new system of harm evaluation to all illicit drugs and
found ecstasy to be significantly less harmful than most other
Class A and even many Class B drugs (Police Foundation, 1999).
When we consider that the possession of a drug that is much less
dangerous than alcohol can lead to a 7 year prison sentence,
whereas alcohol use is actively promoted, perhaps David Cameron
did not go far enough? The recent Foresight report ‘Brain
science, addiction and drugs’ has highlighted the paradoxical
distinctions in regulation of alcohol and tobacco compared with
other drugs (Foresight, 2005). Given the current situation
apparently increases the harms of alcohol perhaps it is time for
a sensible public debate on these issues.

Table 1 Relative harms of the two E drugs
-----------------------------------------

                                  ethanol                ecstasy
------------------------------------------------------------------
Premature Deaths pa UK           22000                     10
Safety in overdose                  10 x   pleasure dose   15 x
Brain damage                         yes                 unsure
Interpersonal violence            10000+  cases per yr       0
RTA deaths pa                       1500                      0
cirrhosis                            ++ and growing            0
Heart damage                         ++                      0
Costs to society                £B  18.5                   0.01
Cont'n to the exchequer   £B    50                      0

RTA = road traffic accidents

References
----------
* Foresight (2005) Brain science, addiction and drugs. Available
online:
http://www.foresight.gov.uk/Brain_Science_Addiction_and_Drugs/index.htm
* Grinspoon L, Bakalar J B (1986) Can drugs enhance
psychotherapy? American Journal of Psychotherapy 40(3): 393-404
* Police Foundation (1999) Drugs and the Law. In, Report of the
Independent Inquiry into the Misuse of Drugs Act 1971. Police
Foundation: London
* Rannia L (2003) Alcohol misuse: how much does it cost?
Strategy Unit  Cabinet Office: London
* Sessa B (2005) Can psychedelics have a role in psychiatry once
again? British Journal of Psychiatry 186: 457-458

Corresponding author: David J. Nutt, Psychopharmacology Unit,
University of Bristol, Dorothy Hodgkin Building, Whitson Street,
Bristol BS1 3NY, UK.
Email: david.j.nutt@bristol.ac.uk

"A tale of two Es", Journal of Psychopharmacology 20(3) (2006)
pp 315-317
© 2006 British Association for Psychopharmacology
ISSN 0269-8811
SAGE Publications Ltd, London, Thousand Oaks, CA and New Delhi
10.1177/0269881106064592