November 2, 2010 Liz Borkowski, MPH 12Comment

The Associated Press article title “Study: Alcohol more lethal than heroin, cocaine” succeeded in getting me to click through to the article. When I did, I wasn’t surprised to learn that the study in question didn’t actually find alcohol to be more lethal than heroin. What it concluded was that alcohol is the most harmful drug (out of 20 studied) when harms both to users and to those around them are tallied.

The study — authored by David J. Nutt, Leslie A. King, and Lawrence D. Phillips and published in The Lancet — used multicriteria decision analysis modelling to assess the harms caused by 20 different drugs used in the UK. During a one-day interactive workshop, members of the Independent Scientific Committee on Drugs (“a new organisation of drug experts independent of government interference”) met to score drugs on 16 criteria and weight the criteria based on their relative importance. The criteria considered harms to both individual users and to others — with the “others” category including society as a whole as well as those directly influenced by drug users. The 16 criteria fall into five categories:

  • Physical harm to users: Drug-specific mortality, drug-related mortality, drug-specific damage, drug-related damage.
  • Psychological harm to users: Dependence, drug-specific impairment of mental functioning, drug-related impairment of mental functioning
  • Social harm to users: Loss of tangibles, loss of relationships
  • Physical and psychological harm to others: Injury
  • Social harm to others: Crime, environmental damage, family adversities, international damage, economic cost, community

The criteria definitions paint a disturbing picture of the many ways drugs harm both individuals and society. Mortality can be caused directly by a lethal dose of a drug, or indirectly by lung cancer or car crashes. Drugs can cause specific damage, like cirrhosis, or lead to related damage, like an HIV infection from sharing needles. Drug users may be more likely to perpetrate domestic violence or cause deadly car crashes, and some drugs can lead to an increase in acquisitive crime. Drug use can contribute to family breakdowns and decline in a community’s social cohesion and reputation. The production of drugs can cause local environmental damage (e.g., from meth labs), and international damage through deforestation and international crime. The direct economic costs – health care, police, social services, etc. – and indirect costs, such as loss of productivity, can add up quickly.

Using this methodology, the study found alcohol to be the most harmful drug, and cannabis the eighth. The top ten are ranked as follows:

  1. Alcohol
  2. Heroin
  3. Crack cocaine
  4. Metamfetamine
  5. Cocaine
  6. Tobacco
  7. Amfetamine
  8. Cannabis
  9. GHB (γ hydroxybutyric acid)
  10. Benzodiazepines

The authors also report which drugs were the most harmful to users and to others, when the groups are considered separately:

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).

Because scores and weights were decided over the course of a single day by a relatively small (15-member) group of experts, it’s possible that a different group could come up with different results — although the authors note that their results are similar to those from similar analyses in the UK and Netherlands and correlate highly with objective data on health and economic costs.

The important takeaway from the study isn’t the exact numerical scores, but the observation that current UK drug policy doesn’t reflect the relative harms of different drugs. The study was funded by the nonprofit Centre for Crime and Justice Studies, and that organization’s press release emphasizes that “the relative harms of legal drugs such as alcohol and tobacco are greater than those of a number of illegal drugs, including cannabis, LSD, and ecstasy.”

The study doesn’t recommend specific drug-policy reforms, and study author Leslie King told the Associated Press alcohol is too embedded in our culture to prohibit successfully. I do hope that such research might inform drug sentencing practices, though. For instance, I suspect multi-year jail terms for possession of marijuana — which exact heavy tolls the individuals, their families, and their communities, as well as on taxpayers who pay for incarceration — are often more harmful than pot smoking.

12 thoughts on “Tallying the Toll of Drugs – On Users and Others

  1. The question I wonder is the weighting they used. Alcohol, tobacco, and cannabis have exponentially more users (and abusers) than the other substances, and the former two orders of magnitude greater than last one. How is that considered? Millions upon millions can use alcohol safely, but is there a safe use for tobacco? As for the dangers of alcohol, the benefits also have a substantial tradition; e.g., Drinking beer in a blissful mood: Alcohol production, operational chains, and feasting in the ancient world, by Jennings, et al. documents the need for alcohol as a “social lubricant.”

    I also believe that drug use better approached as a public health problem than as a criminal problem. If a heroin addict steals to support his/her habit, then punish the stealing, but treat the addiction as a health issue. Too much of our approach is using one tool, a hammer, in the box. We need to look for other ways.

  2. Onkel Bob, I’m also curious about how the committee members dealt with the differences in the size and composition of the populations that use the different drugs. It seems like it would be hard to compare a drug like alcohol that’s used unproblematically by millions (e.g., one glass of wine with dinner) to a drug like heroin that’s used by a small portion of the population – and my guess is that heroin users tend to share certain characteristics, like a greater tolerance for risk, that are less prevalent in the general population.

    And I completely agree with you about taking a public health approach to addiction. It’s too bad that elected officials who lean in that direction are vulnerable to being smeared as “soft on crime.”

  3. I don’t see how the authors of this study can tease out the intrinsic harmfulness of these substances from the harm caused by them being illegal, and doubt that they even attempt to do so. For instance, if heroin of known quality & quantity was sold legally, there’d be few if any overdoses besides intentional overdoses as suicide attempts. Similar effects pertain to all these substances. The harm they cause to users & others is to a large extent an artifact of them not being available legally and of standardized purity & amount.

  4. Can’t let the last comment pass. I had a good bit to do with drug research over several years. Some things are well-established. Most heroin overdoses are not because of extra purity or impurity. Countries where heroin is widely available, and taking it not in itself punishable (eg Pakistan, Shan States in Burma) still subject addicts to very severe social sanctions. Basically, the psychological effects means that few heroin users are able to function socially (ie work, raise children), so a large group of users cannot be supported.

    Legalisation (addict maintenance) works to keep heavily dependent users out of crime. But it’s essentially hospice care – one chilling statistic is that around 40% of dependent heroin users will be dead after 15 years. Treatment policy does not make much difference to this.

    Less familiar with the other, but crack cocaine and crystal methamphetamine both cause psychoses – lots of random violence. Both burn out users within a few years.

    A sad fact is that most drug treatment regimes have low success rates, so keeping the initiation rate low is one key to success. Illegality seems to help this (compare proportions of smokers and drinkers to illegal drug users). But it has to be coupled with lost of complementary policies.

  5. Countries where heroin is widely available, and taking it not in itself punishable.. ..still subject addicts to very severe social sanctions.

    So how do you tease out the adverse physiological or toxicological effects of these substances from the adverse effects due “to very severe social sanctions” pertaining to their use?

  6. Darwinsdog

    There are lots of studies on the physiological effects of illicit drugs. From a purely physiological point of view, heroin is less harmful than many other drugs. But it is addictive (about 1 in 4 people who try it become dependent), and, psychologically, it leads to very asocial behaviour. Heroin users mostly don’t care about other people except as a means to get heroin, or in intervals between use. So they are exploitative, neglectful of children and work, and just give up and die of anomie in the last stages of dependency.

    Much the same for crack and ice, but with violence. So the choice is to sanction use, which limits the number of users, or sanction the behaviour flowing from use, which overloads society as use spirals (see the US black experience with crack).

    In the absence of effective treatment, there are no good choices.

  7. From a purely physiological point of view, heroin is less harmful than many other drugs.

    So why is it illegal?

    But it is addictive..

    Indeed. Heroin is addictive because it binds to a receptor on a post-synaptic neuron which has a particular neurotransmitter as its natural substrate. This, in turn, feeds back on genes that code for enzymes involved in the synthesis of the neurotransmitter, repressing their expression. Hence, in the absence of the artificial substrate (heroin) neural networks are inhibited since the natural substrate is depleted or absent likewise. This is a well known mechanism and operates in all cases of physiological addiction. This mechanism applies equally to nicotine addiction. So why is the fact that heroin is addictive used to rationalize legal sanctions against it but not so used against nicotine? Isn’t this double standard arbitrary and irrational?

    Heroin users mostly don’t care about other people except as a means to get heroin..

    I would contend that to the extent there is any truth to this statement, it is an artifact of heroin being illegal and relatively difficult to obtain. Were heroin legal and readily available and of standardized purity, there would be no incentive for addicts to exploit others as a means of getting heroin or money for buying heroin at an artificially inflated price on the black market.

    So they are exploitative, neglectful of children and work, and just give up and die of anomie in the last stages of dependency.

    These allegations are value judgments that lack scientific merit. Even if there is some truth to them, I would contend once again that they are artifacts of heroin’s illegal status more so than being inherent to the substance itself. And how exactly does one die of anomie?

    Peter T, I contend that your stance on this issue reflects your personal bias against illegal drugs more than it reflects any objective considerations.

  8. When looking at the toll illegal drugs imparts on society, one needs to include the harm caused by the spread of blood-borne disease (menioned briefly above.) In 16 years, Australia saved an estimated 4,500 lives and saved (an estimated) as much as $7.7 billion in health-care related costs due to reduced rates of HIV and Hepatitis infections by instituting needle exchange programs. Ref. MJA 2003 178 (5): 197-198

  9. Darwinsdog

    Most drugs change your brain – that’s why people take them. Some change your brain in ways that make you less able to function socially. This effect can be pretty hard to undo.

    I have no particular animus against drugs as such – I have taken a few illegal ones myself. And I think the present legal status of drugs is nonsensical – it makes illegal drugs that are mostly harmless, others where the evidence is mixed, and others that are definitely harmful. So if I were in charge of policy, I would definitely de-criminalise some illegal drugs.

    My arguments are about some specific drugs – heroin, ice, crack cocaine – where all the evidence is that we have no reliable cure for addiction, that the changes to the brain are mostly in harmful directions, and the consequences for the user and for those around them pretty severe. I came to this conclusion after looking at a lot of evidence, knowing a lot of users and talking to and professionally interacting with drug experts. Few experts buy the “make it legal and the harm diminishes” line – the evidence does not support it.

    For some idea – have a look at this talk by Alan Leshner at

    The behavioural changes he mentions are supported by MRI scans – these support the contentions you label unscientific. And hard to see why dependent heroin users are treated harshly in the Shan States (where heroin is cheap and only as illegal as a village cares to make it) if these are the primary cause. An anthropologist of my acquaintance said it was because heavy users are useless – and villages cannot afford useless healthy adults. We can afford to be more lenient – and should be – but we still have no cure.

  10. Özellikle son zamanların en popüler cilt yenileme ürünüdür. Pembe Maske bir çok ünlü isim tarafından da yoğun olarak kullanılmaktadır. Yüzdeki kırışıklıklar, sivilce ve sivilcelerin sebep olduğu deformasyonları gidermede kullanılan Pembe yüz maskesi ve inceltici, selülit giderici olarak kullanılan pembe vücut maskesi olmak üzere iki farklı ürün mevcuttur.

  11. The cumulative effect of substance abuse cannot be underestimated. When drug abuse occurs in the life of an individual, many other lives are adversely affected. There is hope in the message that recovery is possible, even when addictions to heroin are established.

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