Fast track — ArticlesDrug harms in the UK: a multicriteria decision analysis
Introduction
Drugs including alcohol and tobacco products are a major cause of harms to individuals and society. For this reason, some drugs are scheduled under the United Nations 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances. These controls are represented in UK domestic legislation by the 1971 Misuse of Drugs Act (as amended). Other drugs, notably alcohol and tobacco, are regulated by taxation, sales, and restrictions on the age of purchase. Newly available drugs such as mephedrone (4-methylmethcathinone) have recently been made illegal in the UK on the basis of concerns about their harms, and the law on other drugs, particularly cannabis, has been toughened because of similar concerns.
To provide better guidance to policy makers in health, policing, and social care, the harms that drugs cause need to be properly assessed. This task is not easy because of the wide range of ways in which drugs can cause harm. An attempt to do this assessment engaged experts to score each drug according to nine criteria of harm, ranging from the intrinsic harms of the drugs to social and health-care costs.1 This analysis provoked major interest and public debate, although it raised concerns about the choice of the nine criteria and the absence of any differential weighting of them.2
To rectify these drawbacks we undertook a review of drug harms with the multicriteria decision analysis (MCDA) approach.3 This technology has been used successfully to lend support to decision makers facing complex issues characterised by many, conflicting objectives—eg, appraisal of policies for disposal of nuclear waste.4 In June, 2010, we developed the multicriteria model during a decision conference,5 which is a facilitated workshop attended by key players, experts, and specialists who work together to create the model and provide the data and judgment inputs.
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Study design
The analysis was undertaken in a two-stage process. The choice of harm criteria was made during a special meeting in 2009 of the UK Advisory Council on the Misuse of Drugs (ACMD), which was convened for this purpose. At this meeting, from first principles and with the MCDA approach, members identified 16 harm criteria (figure 1). Nine relate to the harms that a drug produces in the individual and seven to the harms to others both in the UK and overseas. These harms are clustered into five
Results
Figure 1 shows the 16 identified harm criteria. Figure 2 shows the total harm score for all the drugs and the part-score contributions to the total from the subgroups of harms to users and harms to others. The most harmful drugs to users were heroin (part score 34), crack cocaine (37), and metamfetamine (32), whereas the most harmful to others were alcohol (46), crack cocaine (17), and heroin (21). When the two part-scores were combined, alcohol was the most harmful drug followed by heroin and
Discussion
The results from this MCDA analysis show the harms of a range of drugs in the UK. Our findings lend support to the conclusions of the earlier nine-criteria analysis undertaken by UK experts1 and the output of the Dutch addiction medicine expert group.8 The Pearson correlation coefficient between Nutt and colleagues' 2007 study1 and the new analysis presented here for the 15 drugs common to both studies is 0·70. One reason for a less-than-perfect correlation is that the scores from Nutt and
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