Alcohol Is More Harmful Than Heroin, Crack

Fran Lowry

November 03, 2010

November 3, 2010 — Alcohol is more harmful both to the individual and to others than heroin and crack, according to a new study published online November 1 in The Lancet.

"To provide better guidance to policy makers in health, policing, and social care, the harms that drugs cause need to be properly assessed," write David J. Nutt, MD, Imperial College, London, United Kingdom, and the Independent Scientific Committee on Drugs, and colleagues. "This task is not easy because of the wide range of ways in which drugs can cause harm."

Dr. Nutt and his team tackled the thorny issue of trying to tease out how various drugs ranked according to the harm they caused by creating a new scale of drug harms.

The investigators had previously tried to do this in 2007, when they engaged experts to score licit and illicit drugs according to 9 criteria of harm, which ranged from the intrinsic harms of the drugs to social and healthcare costs.

That analysis prompted much public debate but also raised concerns about the 9 criteria that were chosen and the fact that differential weighting of the criteria was lacking, the study authors note.

In the present study, Dr. Nutt and colleagues undertook a review of drug harms using the multicriteria decision analysis approach, a special approach that has been shown to be useful to help decision makers who face particularly complex issues with many conflicting objectives.

The multicriteria decision analysis (MCDA) model assessed 20 drugs most commonly used in the United Kingdom for their potential to cause 16 harms, as listed below:

  • Drug-specific mortality;

  • Drug-related mortality;

  • Drug-specific damage;

  • Drug-related damage;

  • Dependence;

  • Drug-specific impairment of mental functioning;

  • Drug-related impairment of mental functioning;

  • Loss of tangibles (job, housing, income, etc);

  • Loss of relationships;

  • Injury;

  • Crime;

  • Environmental damage;

  • Family adversities (eg, family breakdown, child neglect, etc);

  • International damage;

  • Economic cost; and

  • Community.

Drugs were scored on a points scale of 100, with 100 being the most harmful drug and zero being something that caused no harm at all.

The study found that overall, according to the new MCDA model, alcohol was the most harmful drug, with an overall harm score of 72. Heroin came second, with a harm score of 55, and crack, with a harm score of 54, came third.

Heroin, crack, and crystal meth (harm score, 33) were the most harmful drugs to the individual, whereas alcohol, heroin, and crack were the most harmful to others.

Harm Scores

The overall harm scores for the other drugs that were assessed were:

  • Cocaine – 27;

  • Tobacco – 26;

  • Amphetamine/speed – 23;

  • Cannabis – 20;

  • γ-Hydroxybutyric acid – 18;

  • Benzodiazepines (eg, valium) – 15;

  • Ketamine – 15;

  • Methadone – 14;

  • Mephedrone – 13;

  • Butane – 10;

  • Khat – 9;

  • Ecstacy – 9;

  • Anabolic steroids – 9;

  • Lysergic acid diethylamide – 7;

  • Buprenorphine – 6; and

  • Mushrooms – 5.

According to the model, not only was alcohol the most harmful drug overall, it was almost 3 times as harmful as cocaine or tobacco and 5 times more harmful than mephedrone, a drug that was legal in the United Kingdom before it was made a controlled substance in April 2010. Ecstasy was only one-eighth as harmful as alcohol, the investigators reported.

"Our findings lend support to previous work in the UK and the Netherlands, confirming that the present drug classification systems have little relation to the evidence of harm," Dr. Nutt and colleagues conclude. "They also accord with the conclusions of previous expert reports that aggressively targeting alcohol harms is a valid and necessary public health strategy."

In a linked commentary, Jan van Amsterdam, National Institute for Public Health and the Environment, Bilthoven, Netherlands, and Wim van den Brink, Amsterdam Institute for Addiction Research, Amsterdam, Netherlands, write that the ranking of drugs in terms of their harm to individuals and to society that was done in this study "provide a useful aid for politicians and policy makers for how to classify (illicit) drugs, with the ultimate goal to establish an effective and proportionate drug classification."

But they point out that this ranking is not definitive because the pattern of recreational drug use is dynamic, changing according to the popularity and availability of the drugs.

They conclude, "It is intriguing to note that the two legal drugs assessed — alcohol and tobacco —score in the upper segment of the ranking scale, indicating that legal drugs cause at least as much harm as do illegal substances."

Study Is Timely

Itai Danovitch, MD, director of Addiction Psychiatry Clinical Services at Cedars Sinai Medical Center in Los Angeles, California, told Medscape Medical News that this study represents a laudable attempt to quantify and qualify the relative harms of various drugs.

"We are currently in a phase where we have been evaluating whether to reform a number of policy decisions about drugs of abuse," Dr. Danovitch said.

Most policy determinations about whether drugs of abuse should be legal or illegal are based on ideological or political positions and do not rely on the science of the harms of the drug and an understanding of the public health impact associated with the drug, he said.

"A lot of people have suggested that our policy determinations should take into greater account the actual science of what is known about substance abuse.

"The challenge is that you can't just put a number on how harmful a drug is the way you can for a drug that, for example, lowers your blood pressure. So much of the harm of a drug is related to the context in which it is used. If alcohol was used on an island where there wasn't any driving, it wouldn't cause any car accidents."

In the MCDA model used in the study, alcohol did the most harm largely because of the harm it causes to others, he added. "If you just looked at the harm to users, alcohol would actually fall behind heroin, crack, methamphetamine, and cocaine, but because of the ubiquity of its use and because of a lot of things that can happen during intoxication, alcohol ends up doing a lot of damage to other people."

Heated Marijuana Debate

Right now, California is in the throws of a heated debate about whether marijuana should be legalized. The arguments pro and con have swung between 2 extremes, with one side arguing marijuana should be prohibited because it is toxic, and the other side purporting that marijuana is a panacea and medically harmless.

"In this study, they put marijuana midway along the harm cycle, substantially lower than alcohol, cocaine, heroine, and even tobacco. But there are some harms. Maybe our current policy of arresting people for marijuana violations isn't justified by the level of harms caused by cannabis. Policy determinations should balance some ability to address the real potential harms by having appropriate regulations," said Dr. Danovitch said.

"Those kinds of policy determinations require the type of systematic and neutral unbiased analysis seen in this study. This is what they have contributed," he added.

There are twice as many people in the United States with alcohol problems than drug problems, so it is a more prevalent disorder, Dennis Daley, PhD, chief of Addiction Medicine Services at the Western Psychiatric Clinic and professor of psychiatry at the University of Pittsburgh Medical Center in Pennsylvania, told Medscape Medical News.

"A colleague of mine told me that 30 years ago she was on vacation with her family and they went into a small town to go shopping. Right in front of her a drunk driver came up on the sidewalk and killed her 6-year-old daughter and her 61-year-old mother. So you have these innocent victims, or children who are born with fetal alcohol syndrome, you have victims of crime, family problems, all these things," he said.

"Every time a new drug comes on the scene — the new one is methamphetamine — everyone gets in an uproar. But the number 1 problem remains alcohol abuse and alcohol dependence. This article really points that out."

This study was funded by the Centre for Crime and Justice Studies (United Kingdom). Dr. Nutt reports that he received travel expenses to attend the June 2010 meeting held under the auspices of the Independent Scientific Committee on Drugs. Dr. van Amsterdam, Dr. van den Brink, Dr. Danovitch, and Dr. Daley have disclosed no relevant financial relationships.

Lancet. Published online November 1, 2010.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....