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Pontifications on Poison

Being some ramblings on events associated with poisonous plants.

Thursday 29th March 2012

I wrote, yesterday, that I found only one reference to Catha edulis, khat, in the written submissions to the HASC inquiry into drugs policy. Today, thanks to a Tweet from Harry Sumnall, I’ve been reading a 93 page monograph from Australia on the subject.

I was struck by the similarity between the issues concerning the need for and method of achieving control of the availability of khat in Australia with the situation concerning Cannabis sativa, marijuana, in the USA.

The report was funded by Australia’s National Drug Law Enforcement Research Fund and is titled ‘Law enforcement and khat: An analysis of current issues’ and uses results from focus groups of users and interviews with police as well as previously published material.

It begins with five recommendations. Number 3 is ‘Educate community about the law and the health effects of khat’ and it says this is necessary because ‘Most users were unaware of the physical and psychological harms that have been associated with chewing khat’. Recommendation 4 is ‘Conduct further research on health and the need for human studies’. This is necessary because ‘Until such studies are carried out many of the claims about the relationship between khat and negative health outcomes will remain unverified’.

So, users should be warned about the negative health effects of using khat even though the relationship between khat and negative health outcomes is unverified.

The report devotes a whole chapter to the issue of khat and health. The authors begin well enough by pointing out that research on the effects of khat is often conflicting because what one paper blames on khat another finds is the result of ‘the often traumatic effects of immigration that many Australian khat users experience’. But they soon go off the rails by stating ‘However, there is a growing literature on the links between khat use and negative health impacts’.

Whether the literature on khat is growing or not is debatable but what is not is that there remains very little of it. What there is is sometimes repetitive. Volume 87, issue 3 of ‘Heart and Education in Heart’ from 2002 carries a letter entitled ‘Khat chewing and acute myocardial infarction’ dealing with 157 patients over a two year period who were admitted to the intensive care unit of Al-Thawra hospital, Sanaa, Yemen. In May 2005, the British Journal of Clinical Pharmacology published a paper entitled ‘Khat chewing is a risk factor for acute myocardial infarction: a case-control study’ by the same authors and dealing with 100 patients in the same time period at the same hospital. Though the 2005 paper mentions the 2002 letter it gives no explanation for 157 becoming 100.

The monograph references other reports of negative health outcomes in khat chewers including a letter to the New England Journal of Medicine entitled ‘Severe, Acute Liver Injury and Khat Leaves’. This 2010 letter concerns six patients over a five year period whose liver disease could not be explained leaving only the possibility that it resulted from their khat use. What it doesn’t say is how many liver disease patients, in total, had presented in that five year period.

The monograph’s authors don’t question the lack of published information. They give estimates of khat prevalence in Yemen that suggest (based on CIA World Factbook figures for population and taking the lowest estimate) a minimum of 7 million Yemenis chew khat. But, in 2 years, only 125 khat chewers were admitted to hospital in Sanaa for acute myocardial infarction.

It is another Jerry Maguire situation. If khat is so detrimental to health, show me the  bodies?

This is the first point where, it seems to me, there is an analogy between Catha edulis and Cannabis sativa. We keep hearing about the alleged association between cannabis and psychosis but the simple fact that something approaching 200 million people have used cannabis without suffering any harm is ignored. If khat use alone were the cause of some of the health conditions people try and associate with it, hospitals throughout the Middle East and north-east Africa would be overrun.

The other area where I perceive a similarity is with the Australian regime for controlling khat. Like the USA, Australia is a federation of states. Federal law prohibits the importation of khat unless the importer has received a licence permitting shipments of up to 5kg per month for personal use. Where states have laws prohibiting possession of khat the federal government does not issue licences.

There is a problem, however, in that the meaning of ‘importation’ is unclear as is the meaning of ‘personal use’. The licence application does not require the applicant to declare that they will consume the khat and it is open to the interpretation that the importer can, legally, resell the quota. Equally, the definition of importation seems to include bringing khat into a state that permits it and transferring it to one that does not. Thus federal and state laws come into conflict.

Australia is very careful about biological contamination so before an importer can apply for a licence they have to get a permit from the Australian Quarantine and Inspection Service. Then there are those who say that chewing khat makes it a foodstuff and so it should be subject to Australia’s food safety rules.

In other words, the regime for controlling khat is bureaucratic and unwieldy and offers opportunities for those who so wish to enforce their prohibitionist view by using unrelated legislation. It is no surprise that many khat users, for whom English is their second language, have difficulty in understanding the situation. That, in turn, creates suspicion. The monograph’s authors point out that there were problems recruiting people for the focus groups because many of those approached refused to take part as they feared what use might be made of any information they gave.

All of which sounds to me not unlike the regulatory mess that is ‘medical marijuana’ in the USA. Conflicting laws between state and federal governments and confusion over what is and isn’t permitted.

It also seems that, if the focus group statements were taken at face value, you would conclude that khat suppliers are benevolent philanthropists because people claimed that khat was given to them free. The authors attribute this to the widespread belief that having khat is legal but selling it is the offence.

So, as with many other studies, the problem of self-reporting comes in. If researchers recognise that a self-reported situation is illogical, can they make a subjective decision about what the respondents really meant without destroying the credibility of the survey?

The report also has a separate chapter about ‘Khat use and driver impairment’. It suggests that some drivers, especially taxi drivers, deliberately chew khat at work to help them stay awake and concludes that more research is required into the effects of khat on driving ability. That, to me, is missing the point. Given that, were khat not available, these drivers could turn to strong coffee or high-caffeine ‘energy’ drinks to achieve the same result, the research should be directed at what can be done to reduce the perceived need for taxi drivers to work such long shifts, or do a normal day job before driving a cab all night, that they cannot stay awake without artificial assistance.

The monograph's authors limit their recommendations to better explanation of the existing situation but, it seems to me, the comments about driving could be exploited by politicians wishing to press for complete prohibition of Catha edulis by creating the impression that khat chewing drivers are a menace threatening the lives of innocent Australians.

I don’t doubt that members of the Advisory Committee on the Misuse of Drugs (ACMD) will read this monograph as part of the current review of khat in the UK. But, for me, it offers nothing new that changes our understanding of the effects of khatting.