Banning psychoactive substances is not enough, we need education too

Novel Psychoactive Substances (NPSs), also referred to as ‘legal highs’, represent a bewildering array of unregulated psychoactive compounds, marketed globally as legal alternatives to well-known controlled drugs. More than 40 years ago, the synthetic chemist Alexander Shulgin said that, in the future, underground researchers would synthesise novel psychoactive stimulants. Shulgin’s prophecy came true. Over the past ten years, the UK has witnessed the rapid emergence of NPSs, sold over the internet and in high street “head shops” facilitating availability. The content, interactions, side effects and abuse potential of these NPSs are often unknown, not only to users but also to healthcare professionals.

The UK is one of the biggest consumers of NPSs in Europe with frequent reports of serious clinical
and public health issues, particularly for vulnerable groups (prisoners, teenagers, homeless). 58% of NPSs were purchased online in the UK last year and NPS users are three times more likely to end up seeking emergency medical treatment than using traditional drugs. The risk of potential harms, i.e. mental health issues, crime, debt and violence has prompted the UK Parliament to pass the Psychoactive Substances Act 2016. This UK law says that if a person produces, distributes, supplies, imports or exports a substance capable of having a psychoactive effect – nicotine, alcohol, caffeine and medicinal products are excluded – they could receive a prison sentence of up to seven years. Possession is not an offence. 

Legality, drug demand & drug harm

Worryingly for me, the Government seemingly delayed this legislation because it had not established exactly how substances will be tested for ‘psychoactivity’. This will be difficult given the wide range of the psychoactive substances that fall under this law. However, enforcement of this law will be vital to eradicate the open sale of NPSs on high streets, on UK websites and in our prisons. However, the fact that Ireland has struggled to enforce its NPS law (use among young people has not only gone up since their law was introduced in 2010 but use is now the highest in the EU) is cause for concern.
 
If the law is consistently enforced, the fear of imprisonment will no doubt deter open high street and internet sales of NPSs in the UK and make the likes of parents feel safer when their protégé socialise or surf the net. However, prohibition will not address supply of NPSs via the largely untraceable area of the internet, especially the dark net nor will it address drug demand – the basic human desire for seeking pleasure and altered states of consciousness. Worryingly, dark-net purchases are rising (4.5% to 6.7% in the past year) and demands for NPSs made illegal under the UK Misuse of Drugs Act 1971, such as mephedrone, have not significantly changed in the last 3 years indicating that simply making something illegal seems to have little impact on demand. There is also an early indication that future demand is unlikely to shift. A survey of 1,000 16–24 year olds found that nearly two thirds of respondents said that they are likely to continue to use NPSs, despite the ban. NPS use is highest amongst 16–24 year olds who are more likely to enhance their experiences especially in social events (e.g. club nights) with key motivations being curiosity, boredom and peer pressure.

Another consideration is that information from users via blogs or internet sales sites may not present an accurate picture to (potential) consumers. For example, methoxetamine (MXE), an arylcyclohexylamine derivate of ketamine, is a synthetic psychedelic drug with a recent history of use in the UK and globally (it is still uncontrolled in many countries). It was marketed as a legal, safer, ‘bladder friendly’ alternative to the more widely used dissociative anaesthetic ketamine, with no pharmacological evidence to support this claim. Subsequent case reports of MXE users seeking emergency treatment and pharmacological studies indicate that MXE has a similar bladder toxicity to that of ketamine. Similarly, newer legal ketamine derivatives, diphenidine and methoxphenidine, are marketed as ‘bladder safer’ alternatives to ketamine. Removal of high street and internet sales of NPS in the UK will at least remove such false claims and misleading information, particularly to those not wise enough to question the evidence base of the information.

For centuries humans have used various psychoactive substances to achieve altered states of consciousness and seek pleasure, the ancient Greeks, after all, took advantage of the opium poppy and cannabis leaf. Surely then the odds are stacked against this law influencing NPS demand unless there is also a clear communication of the consequences of consuming NPSs. Also, we must not lose sight of the fact that far more prevalent “lawful” psychoactive substances taken in the UK, alcohol and tobacco (exempt of this ban) are more harmful than many illegal drugs, such as cannabis and ecstasy. A national prohibition of alcohol (1920–33) in the US led to an increase in alcohol consumption, crime, imprisonment and a switch to other dangerous illegal substances such as opium, marijuana, and cocaine. The fact that this experiment failed on all counts is an important lesson. This new UK law makes no distinction between very harmful psychoactive substances, such as synthetic opiates and better tolerated ones, such as laughing gas. Ironically, whilst alcohol is legal, “alcosynth” being developed as a safer alternative to alcohol is now banned. This emphasises how legality has little to do with the potential for a drug to cause harm.
 
Surely then the key message the Government needs to convey to society, alongside any drugs regulation, is that, all substances (legal or illegal), including food, drinks and medical products are harmful if consumed in the wrong amounts. Even water. There have been a number of cases where people have died after consuming too much water (hyponaetremia) while on ecstasy. These deaths led to a fairly quick change in the standard harm reduction message back in 1999 “remember to drink water, but don’t drink too much water!”

Drug education is the key to prevention of harm

The misleading terminology ‘legal highs’ has not helped the perception that the term ‘legal’ implies there has been some process of assessment deeming them safe for human consumption. Alongside the law, education is needed to emphasise that ‘if something is legal it does not mean it is safe’ and anything you consume is potentially unsafe, it is simply a matter of how much of it you consume.

Public opinion in Europe ranks information and prevention campaigns as the second most important way for the policy makers to tackle society’s drug problems. Second, that is, to punishing the drug dealers and traffickers, which this new law will do. To address public opinion this law needs to work in tandem with a comprehensive education and targeted public awareness campaign highlighting the potential risks and harms from these substances, particularly for the more vulnerable risk taking 16–24 year olds, parents and teachers. Currently, science is the only statutory subject that delivers drug education in UK schools, and this is largely confined to biological understandings of drugs. Schools are expected to cover other fundamental components of drug education such as resilience to risk factors (e.g. peer pressure) – within personal, social and health education (PSHE). A recent survey of 590 secondary school pupils in London and 288 teachers across England highlights the need for an improvement in national policy on drugs education particularly in relation to subject-specific teacher training and the need for a statutory status for PSHE.

The UK Government has pledged to work with experts (including the Advisory Council on the Misuse of Drugs) to develop a new drugs education strategy but as yet there is no commitment to fund their information services (such as Talk to Frank, Mentor-Alcohol and Drug Education and Prevention Information Service) going into schools and universities to better deliver on evidence-based drugs education. At the moment there are a number of stand-alone public awareness campaigns (e.g. Angelus Foundation, Rise Above) that proactively outreach into schools and communities at a local level. Introducing a statutory PSHE programme into the national curriculum will not only educate but build resilience and empower young people to make positive choices for their health including substance choices, especially when in peer pressure situations. Government support and professional training and development are essential ingredients in the provision of universal drug education in schools.

This new law will not criminalise people for possession of psychoactive substances (unless they are already locked up). But surely educating and empowering people (particularly those in the most vulnerable groups) about the risks of psychoactive substances is key to preventing harm.

Prohibition coupled with easier global sales channels has fuelled the recent demand for legal alternatives. Surely further prohibition will only help reduce demand and, ultimately, harm if everyone is aware of the risks of using psychoactive substances. Only then can we make informed and educated choices about whether or not to use these substances, legal or not.

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