"AN OPEN LETTER TO THE ACMD ABOUT ECSTASY"

 BY PROFESSOR ANDREW PARROTT

The Advisory Council on the Misuse of Drugs has been devoting time to reclassifying ecstasy downwards, even though not requested by government to do so.

Deirdre Boyd recalls parliament’s criticism of the ACMD here.

Read Professor Andrew Parrott’s expert view below.

"After conveying my concerns to the ACMD, its response leaves me with very serious concerns. Indeed, it leaves me even more concerned than I was before.

I cannot believe that I have spent the past 14 years undertaking numerous scientific studies into Ecstasy/MDMA in humans, then for the ACMD to propose downgrading MDMA without a full and very detailed consideration of the extensive scientific evidence on its damaging effects. My research has been published in numerous top quality journals, and can be accessed via my Swansea University webpage here.  

The topics the committee are covering seem to be very limited. It also seems to be relying on meta-analyses – apparently, the ACMD organised that the HTA conduct a NICE-type metanalytical review of all the neurocognitive studies of MDMA. But meta-analysis is inherently limited as a procedure (see final section below). And it seems to be focusing on the longer-term effects of MDMA. This is only one aspect of the dangers of MDMA. Three areas need to be considered.

DANGERS: ACUTE.

MDMA has very powerful effects in all users. Cardiac stimulation, faster breathing, gurning/jaw stimulation....etc. Most recently, we have demonstrated an average 800% increase in the stress hormone cortisol in recreational MDMA users at dance clubs (Parrott et al, 2008). Every acute ecstasy/MDMA user is in a state of strong
metabolic overstimulation. So all users typically display levels of the serotonin syndrome - see my 2002 paper. Car driving, attention and impulsiveness/riskiness are similarly impaired. Hence it is very dangerous in real-life situations - especially in a polydrug context. As a recent study of London hospitals shows, even children are being admitted for care after mixing ecstasy and alcohol.

DANGERS: POST-MDMA RECOVERY.

Low moods, anhedonia, fatigue, disrupted sleep, mid-week depression... It takes several days to recover from MDMA. In frequent users – eg, every weekend – this is a problem for the everyday health and occupational well-being of all ecstasy users (see Topp et al, 1999 for a more detailed coverage). The ACMD should be fully
aware of this – but is it? If it is not fully informed of these, why not?

LONGER-TERM PROBLEMS.

Neurocognitive damage is just one element here, and probably not the most important. There are also frontal-executive deficits and development of impaired immunocompetence over time (Pacifici et al).
Reay et al (2006) demonstrated impaired social intelligence. There is increased oxidative stress and well-publicised psychiatric problems as well as harm to many other functions - see my 2006 review.

At the recent Swinburne MDMA conference which I organised, Una McCann from Johns Hopkins in the US reported on sleep apnea. This was significantly higher in young E users than controls; there is also significantly more sleep apnea in the more experienced lifetime E users. The thoracic medics involved in the study were not surprised – they knew about the serotonergic control components of breathing during sleep etc.

I could go on, but there is plenty more in my published papers. ACMD chair David Nutt and his committee should know all this. So why does it not act on all this empirical information?

The ACMD reply to my concerns seemed to suggest that there are few adverse effects of MDMA. Has it actually read the review articles I sent? It would seem not, according to Nutt’s article in The Lancet in which limited information led to a dubious ‘low harm’ score for MDMA compared with other drugs.

As the committee does not seem to have read my earlier email attaching pdfs of my reviews, as I requested – I reiterate that request here. I also request that they then email me with their understanding about the effects of MDMA on everyday health and wellbeing. Please also forward this email to them. They need to achieve
an in-depth understating about MDMA before they can come to any conclusions. It is inadequate to just sit around and listen to a few people speak one morning, then have a 'vote' on this important question – especially when the outcome seems predetermined, as it was the ACMD which instigated the downgrading in the first place.

The main area which the ACMD has acknowledged is the longer-term effects of regular usage. These are very complex and modulated by numerous co-factors. These I debated at considerable depth and length in my 2006 review, where I concluded that it is indeed damaging in various areas.

Note: When anyone undertakes statistical meta-analyses into the longer term effects of MDMA, all the subtle co-influences tend to be lost, so that only the lowest common denominator can emerge. So it is possible to subject the cannabis and cognition data to 'meta-analyses' and show that its effects are minimal. You can probably do the same with boxing and head injury. I am sure that any decent meta analysis will show that it is safe to be a soldier fighting in a war zone! If you include enough co-variables, and all good and poor studies, the error variance will always tend to dominate and the experimental effect will reduce in size.

This might help to explain to clinicians and policymakers why statistical 'meta-analyses' in the behavioural sciences typically conclude that the effect is there – but is generally weak. In every area of interest, you need to follow a far more intelligent, critical, and theory driven approach to reach a more accurate understanding.

MDMA is certainly a damaging psychoactive drug and it should not be downgraded.

Professor Andy C. Parrott
Department of Psychology
Swansea University, Wales, UK
Swansea SA2 8PP

Comments

[Peter O'Loughlin]

Midst the babble of rhetoric, ideology and 'research', objective in the sense of proving what has already been decided, a voice of reason is finally heard, but seeemingly ignored.

[Steve Duce]

I commend Professor Parrot's stance on this subject but note that the emphasis is on MDMA (admittedly the commonest form) as opposed to the many other type of 'Ecstasy' variations outlined in PIHKAL (some 147 I believe).

Having come from an investigative background my concerns also revolve around the adverse health effects of these types of drugs, perhaps for different, though additional, reasons.

The ACMD should (also) take into account that the manufacture of these drugs is for the mostpart illicit (almost explicitly, other than for research purposes)and therefore has no quality control measures as one might expect from licensed pharmaceutical products.

It follows then that the end users, who are many, have absolutely no idea,

1. If the product is what it has been sold as; and
2. If it contains MDMA for instance, the actual dosage of the product; and
3. What other substances have been used (as dilutants, bulking agents) in the make up of the end product.

I have always been of the opinion that use of these types of preparation is akin to playing Russian Roulette, and whilst I do not consider that reclassification will have any real effect on consumption, it will clearly send out the wrong message to users. Moreso if the reclassification is wrongly highlighted and advertised,as was the case with cannabis

Despite the commendable ongoing research, the long term effects of this type of drug have yet to be properly established. What we do know is that they are, at least in part, responsible for a number of deaths - a negligible number by comparison to some other legal and illegal drugs, but trying telling that to the families of those that have fallen foul.

[Niall Scott]

As usual the aim seems to stop useful debate. If we look at the 'big picture' ecstasy is clearly not as harmful as heroin and cocaine by most criteria therefore the Misuse of drugs act should reflect this. It is easy to take the populist political approach of citing dangers then being able to tut when people ignore your advice - sometimes we have to be brave as a society rather than looking to cover our arses.

Quite how reasonable the misuse of drugs act is in effectively criminalising intoxication which is frankly not anyones business until it impacts on others is another debate.

[Steve Rolles]

There are a number misunderstandings in this letter, but even before it begins we are told that: 'The ACMD has been devoting time to reclassifying ecstasy downwards, even though not requested by government to do so'

The ACMD is devoting time to a review of ecstasy harms (as part of a systematic review of all drugs covered by the MDA), with a view to making a recommendation on classification, as yet undetermined. Their remit, detailed the Misuse of Drugs Act 1971, very clearly spells out that they do not require a request from Government to undertake such work:

“It shall be the duty of the Advisory Council to keep under review the situation in the United Kingdom with respect to drugs which are being or appear to them likely to be misused and of which the misuse is having or appears to them capable of having harmful effects sufficient to constitute a social problem, and to give to any one or more of the Ministers, where either Council consider it expedient to do so or they are consulted by the Minister or Ministers in question, advice on measures (whether or not involving alteration of the law) which in the opinion of the Council ought to be taken for preventing the misuse of such drugs or dealing with social problems connected with their misuse, and in particular on measures which in the opinion of the Council, ought to be taken"

The -as yet unpublished- review (and recommendations) is not, however, completely unbidden, following as it does much public debate on the perceived anomalous classifications, a call for a downgrading of ecstasy (and some other drugs) by the Parliamentary Home Affairs Select Committee in 2001, and a specific call for an 'urgent' review of ecstasy classification from the Parliamentary Science and Technology Committee in 2006.

regards the letter:

1. the prof states that '.....for the ACMD to propose downgrading MDMA without a full and very detailed consideration of the extensive scientific evidence on its damaging effects'. As the review and recommendation are unpublished at this point they have clearly proposed no such thing. Further more they *are* doing a detailed review of the evidence, as they have done with numerous similar reviews of other drugs. I would be interested to hear from the prof if he feels these earlier reports were inadequate, and why.

2. Having been at the recent open session, which I believe neither Prof Parrot, nor Deidre Boyd attended (Im happy to be corrected on this)It was quite clear that all the dangers listed in the above letter were very much being considered, and that the systematic literature review they have commissioned (which it is worth highlighting, is not the same as a meta-analysis) was as thorough and methodologically sound as could be hoped for - considering over 1400 separate studies, of which around 400 were deemed of sufficient quality for inclusion. The committee has also received numerous additional written submissions, presumably including Prof Parrots, which members had in one terrifyingly think phone book-like printed and ring bound volume.

So despite demonstrably not knowing what work the committee have done, what studies they have considered or how, and having not read the report (because it is neither completed nor published) let alone being privy to its conclusions, the prof makes a series of sweeping statements, and indeed judgments, on all of the above.

I cannot help but feel this is highly inappropriate and like Deidre's earlier blog is a baseless sleight on the committees chair, members and work.

[Peter O'Loughlin]

The pro drug lobby, once again show their eagerness to divert from the evidence which clearly establishes the total harms caused by ecstasy, with their shoal of 'red herrings'.

This is a standard ploy which is best ignored. Let's focus on the evidence and endevour to persuade the acmd to do the same, rather than the idoelogical rhetoric which is being emplpoyed in the hope of burying scientific and empirical evidence.

[Kathy Gyngell]

Addiction Today is to be congratulated on its courage in raising this important issue - not least because it was one likely to generate a hostile and defensive response from those who lobby for legalisation of drugs - which indeed it did.

But whatever one's position on prohibition, it must be in everyone's best interests to bring expert research about the dangers of a drug into the public arena - research that is clearly neither widely known nor understood - and activating debate about that research.

Adult ecstasy use in the UK is already nearly double than in the Netherlands and six times higher than France and Sweden. We have yet to live out the health, mental-health and social consequences of this level of use in the population or of the impact of children's early introdution to the drug.

We are facing, in this country, already, much higher levels of teenage (and earlier) polydrug use on top of much higher levels of alcohol intoxication than any of our European counterparts. That this may reflect both a laissez faire attitude towards their use, as well as the totally inadequate communication of their short-term and long-term risks by the various bodies tasked with this responsibility, including the ACMD, is of deep concern.

I cannot therefore understand why Professor Parrott's important and expert contribution to the debate and investigation that the ACMD is conducting is not welcomed by all.

He is surely right to argue that not one of these drugs can any longer reasonably be looked at solely outside the context of its use with other drugs and stimulants, and must be right to highlight ectasy's dangers in this context? Given his knowledge, to do otherwise would surely be irresponsible?

The ACMD itself is certainly not above criticism in the way it has conducted itself in the past. Their current exercise on ecstasy is redolent of past problems. You have to be more than forgiving not to see where Professor Nutt is coming from. So it is now contingent on the ACMD itself to meet its critics and to demonstrate that it does not have a 'default' position on the down classification of certain drugs. It needs to actively demonstrate total neutrality in these matters and show that its investigations go beyond 'going by the book'.

It needs also, I believe, to also demonstrate its social concern and social responsibility, whatever the small print of their terms of reference.

It is of huge concern that the lead scientist in this area should be doubting whether the ACMD is taking real heed of his research and expertise; or whether indeed the ACMD has taken on board his expert critique of the limitations of meta analysis. It does seem most strange that the ACMD did not and has not actively sought the advice of Professor Parrott in the first place, as a lead 'ecstasy expert', for their review. Could this suggest perhaps a certain arrogance or an unwillingness to engage with opinion different to its own default position?

[Steve Rolles]

I have posted a detailed response to Kathy's comment on the previous blog by Diedre (on which she has posted it).

But to add: The Prof has no evidence to suggest the committee has ignored the research he has submitted. My understanding is that they did no such thing - all submissions have been welcomed and considered.

[Peter O'Loughlin]

Whether or not they were toxicologists on the ACMD committee when the inexplicable decision to recommend downgrading of cannabis was made, is something I have no way of knowing, but if as it appears as part of their diversionary tactics, the pro drug lobby want to claim there were, perhaps they would care to name them.

I am unable to see from the recorded documentary that Mary Brett alleged that the members were not anti drug, according to her quoted comments at the time, she pointed out the inescapable truth that representation from drug prevention use representatives were non existent as compared to those on the committee, whose views appear to be what might be kindly described as liberal when it comes to the use of toxic, psycho active drugs of destruction.

Nor for that matter is there any record of Mary Brett saying there were no psychiatrists on the committee, what she did note in common with others, was the lack of psychiatrists whose speciality is psychosis, especially cannabis induced psychosis.

The misrepresentations by the pro drug lobby are designed to serve two purposes to seek to discredit those who prefer not to see further damage caused to our society, by the unnecessary liberalisation of toxic psycho active substances, and to divert from the evidence which clearly shows why ecstasy should not be downgraded.

The latter has been noticeable throughout the postings so I will not be responding to the anticipated screams of protest, thus aiding and abetting the pro drug lobby in their strategy of diversion.

[Deirdre Boyd]

ON 17 NOVEMBER 2008,the Home Office invited Professor Parrott to give evidence at the ACMD Open Meeting scheduled for 25 November.