Health PolicyDevelopment of a rational scale to assess the harm of drugs of potential misuse
Introduction
Drug misuse is one of the major social, legal, and public-health challenges in the modern world. In the UK, the total burden of drug misuse, in terms of health, social, and crime-related costs, has been estimated to be between £10 billion and £16 billion per year,1 with the global burden being proportionately enormous.2, 3
Current approaches to counter drug misuse are interdiction of supply (via policing and customs control), education, and treatment. All three demand clarity in terms of the relative risks and harms that drugs engender. At present, in the UK, attitudes to policing and the punishments for possession and supply of drugs are scaled according to their classification under the Misuse of Drugs Act of 1971,4 while education and health-care provision are nominally tailored to the known actions and harms of specific drugs. Most other countries and international agencies—eg, the UN and WHO—have drug classification systems that purport to be structured according to the relative risks and dangers of illicit drugs. However, the process by which harms are determined is often undisclosed, and when made public can be ill-defined, opaque, and seemingly arbitrary. In part, this lack of clarity is due to the great range and complexity of factors that have to be taken into account in estimation of harm and the fact that scientific evidence is not only limited in many of the relevant areas but also evolves progressively and in unpredictable ways.
These qualifications apply to the evidence base of the current UK Misuse of Drugs Act, in which drugs are segregated into three classes—A, B, and C—that are intended to indicate the dangers of each drug, class A being the most harmful and class C the least. The classification of a drug has several consequences, in particular determining the legal penalties for importation, supply, and possession, as well as the degree of police effort targeted at restricting its use. The current classification system has evolved in an unsystematic way from somewhat arbitrary foundations with seemingly little scientific basis.
Here, we suggest a new system for assessing the potential harms of individual drugs on the basis of fact and scientific knowledge. This system is able to respond to evolving evidence about the potential harm of current drugs and to rank the threat presented by any new street drug.
Section snippets
Categories of harm
There are three main factors that together determine the harm associated with any drug of potential abuse: the physical harm to the individual user caused by the drug; the tendency of the drug to induce dependence; and the effect of drug use on families, communities, and society.5, 6, 7, 8
Assessment of harm
Table 1 shows the assessment matrix that we designed, which includes all nine parameters of risk, created by dividing each of the three major categories of harm into three subgroups, as described above. Participants were asked to score each substance for each of these nine parameters, using a four-point scale, with 0 being no risk, 1 some, 2 moderate, and 3 extreme risk. For some analyses, the scores for the three parameters for each category were averaged to give a mean score for that
Results
Use of this risk assessment system proved straightforward and practicable, both by questionnaire and in open delphic discussion. Figure 1 shows the overall mean scores of the independent expert group, averaged across all scorers, plotted in rank order for all 20 substances. The classification of each substance under the Misuse of Drugs Act is also shown. Although the two substances with the highest harm ratings (heroin and cocaine) are class A drugs, overall there was a surprisingly poor
Discussion
The results of this study do not provide justification for the sharp A, B, or C divisions of the current classifications in the UK Misuse of Drugs Act. Distinct categorisation is, of course, convenient for setting of priorities for policing, education, and social support, as well as to determine sentencing for possession or dealing. But neither the rank ordering of drugs nor their segregation into groups in the Misuse of Drugs Act classification is supported by the more complete assessment of
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