Health Policy

Development of a rational scale to assess the harm of drugs

of potential misuse
David Nutt, Leslie A King, William Saulsbury, Colin Blakemore

Drug misuse and abuse are major health problems. Harmful drugs are regulated according to classification systems that Lancet 2007; 369: 1047–53
purport to relate to the harms and risks of each drug. However, the methodology and processes underlying classification See Comment page 972
systems are generally neither specified nor transparent, which reduces confidence in their accuracy and undermines Psychopharmacology Unit,
health education messages. We developed and explored the feasibility of the use of a nine-category matrix of harm, with University of Bristol, Bristol,
UK (Prof D Nutt FMedSci);
an expert delphic procedure, to assess the harms of a range of illicit drugs in an evidence-based fashion. We also included
Forensic Science Service,
five legal drugs of misuse (alcohol, khat, solvents, alkyl nitrites, and tobacco) and one that has since been classified London, UK (L A King PhD);
(ketamine) for reference. The process proved practicable, and yielded roughly similar scores and rankings of drug harm Police Foundation, London
when used by two separate groups of experts. The ranking of drugs produced by our assessment of harm differed from (W Saulsbury MA); Medical
Research Council, London
those used by current regulatory systems. Our methodology offers a systematic framework and process that could be
(Prof C Blakemore FRS); and
used by national and international regulatory bodies to assess the harm of current and future drugs of abuse. Department of Physiology,
Anatomy and Genetics, Oxford,
Introduction Here, we suggest a new system for assessing the UK (Prof C Blakemore)
Drug misuse is one of the major social, legal, and potential harms of individual drugs on the basis of fact Correspondence to:
Prof David Nutt,
public-health challenges in the modern world. In the UK, and scientific knowledge. This system is able to respond
Psychopharmacology Unit,
the total burden of drug misuse, in terms of health, to evolving evidence about the potential harm of current University of Bristol, Bristol
social, and crime-related costs, has been estimated to be drugs and to rank the threat presented by any new street BS1 3NY, UK
between £10 billion and £16 billion per year,1 with the drug. [email protected]
global burden being proportionately enormous.2,3
Current approaches to counter drug misuse are Categories of harm
interdiction of supply (via policing and customs control), There are three main factors that together determine the
education, and treatment. All three demand clarity in harm associated with any drug of potential abuse: the
terms of the relative risks and harms that drugs engender. physical harm to the individual user caused by the drug;
At present, in the UK, attitudes to policing and the the tendency of the drug to induce dependence; and the
punishments for possession and supply of drugs are effect of drug use on families, communities, and
scaled according to their classification under the Misuse society.5–8
of Drugs Act of 1971,4 while education and health-care
provision are nominally tailored to the known actions Physical
and harms of specific drugs. Most other countries and Assessment of the propensity of a drug to cause physical
international agencies—eg, the UN and WHO—have harm—ie, damage to organs or systems—involves a
drug classification systems that purport to be structured systematic consideration of the safety margin of the
according to the relative risks and dangers of illicit drugs. drug in terms of its acute toxicity, as well as its likelihood
However, the process by which harms are determined is to produce health problems in the long term. The effect
often undisclosed, and when made public can be of a drug on physiological functions—eg, respiratory
ill-defined, opaque, and seemingly arbitrary. In part, this and cardiac—is a major determinant of physical harm.
lack of clarity is due to the great range and complexity of The route of administration is also relevant to the
factors that have to be taken into account in estimation of assessment of harm. Drugs that can be taken
harm and the fact that scientific evidence is not only intravenously—eg, heroin—carry a high risk of causing
limited in many of the relevant areas but also evolves sudden death from respiratory depression, and therefore
progressively and in unpredictable ways. score highly on any metric of acute harm. Tobacco and
These qualifications apply to the evidence base of the alcohol have a high propensity to cause illness and death
current UK Misuse of Drugs Act, in which drugs are as a result of chronic use. Recently published evidence
segregated into three classes—A, B, and C—that are shows that long-term cigarette smoking reduces life
intended to indicate the dangers of each drug, class A expectancy, on average, by 10 years.9 Tobacco and alcohol
being the most harmful and class C the least. The together account for about 90% of all drug-related deaths
classification of a drug has several consequences, in in the UK.
particular determining the legal penalties for importation, The UK Medicines and Healthcare Regulatory
supply, and possession, as well as the degree of police Authority, in common with similar bodies in Europe, the
effort targeted at restricting its use. The current USA, and elsewhere, has well-established methods to
classification system has evolved in an unsystematic way assess the safety of medicinal drugs, which can be used
from somewhat arbitrary foundations with seemingly as the basis of this element of risk appraisal. Indeed
little scientific basis. several drugs of abuse have licensed indications in

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medicine and will therefore have had such appraisals, withdrawal reactions—eg, tremors, diarrhoea, sweating,
albeit, in most cases, many years ago. and sleeplessness—when drug use is stopped. These
Three separate facets of physical harm can be identified. effects indicate that adaptive changes occur as a result of
First, acute physical harm—ie, the immediate effects (eg, drug use. Addictive drugs are generally used repeatedly
respiratory depression with opioids, acute cardiac crises and frequently, partly because of the power of the craving
with cocaine, and fatal poisonings). The acute toxicity of and partly to avoid withdrawal.
drugs is often measured by assessing the ratio of lethal Psychological dependence is also characterised by
dose to usual or therapeutic dose. Such data are available repeated use of a drug, but without tolerance or physical
for many of the drugs we assess here.5–7 Second, chronic symptoms directly related to drug withdrawal. Some drugs
physical harm—ie, the health consequences of repeated can lead to habitual use that seems to rest more on craving
use (eg, psychosis with stimulants, possible lung disease than physical withdrawal symptoms. For instance,
with cannabis). Finally, there are specific problems cannabis use can lead to measurable withdrawal symptoms,
associated with intravenous drug use. but only several days after stopping long-standing use.
The route of administration is relevant not only to acute Some drugs—eg, the benzodiazepines—can induce
toxicity but also to so-called secondary harms. For psychological dependence without tolerance, and physical
instance, administration of drugs by the intravenous withdrawal symptoms occur through fear of stopping. This
route can lead to the spread of blood-borne viruses such form of dependence is less well studied and understood
as hepatitis viruses and HIV, which have huge health than is addiction but it is a genuine experience, in the
implications for the individual and society. The potential sense that withdrawal symptoms can be induced simply by
for intravenous use is currently taken into account in the persuading a drug user that the drug dose is being
Misuse of Drugs Act classification and was treated as a progressively reduced although it is, in fact, being
separate parameter in our exercise. maintained at a constant level.10
The features of drugs that lead to dependence and
Dependence withdrawal reactions have been reasonably well
This dimension of harm involves interdependent characterised. The half-life of the drug has an
elements—the pleasurable effects of the drug and its effect—those drugs that are cleared rapidly from the body
propensity to produce dependent behaviour. Highly tend to provoke more extreme reactions. The
pleasurable drugs such as opioids and cocaine are pharmacodynamic efficacy of the drug also has a role; the
commonly abused, and the street value of drugs is more efficacious it is, the greater the dependence. Finally,
generally determined by their pleasurable potential. the degree of tolerance that develops on repeated use is
Drug-induced pleasure has two components—the initial, also a factor: the greater the tolerance, the greater the
rapid effect (colloquially known as the rush) and the dependence and withdrawal.
euphoria that follows this, often extending over several For many drugs there is a good correlation between
hours (the high). The faster the drug enters the brain the events that occur in human beings and those observed in
stronger the rush, which is why there is a drive to studies on animals. Also, drugs that share molecular
formulate street drugs in ways that allow them to be specificity (ie, that bind with or interact with the same
injected intravenously or smoked: in both cases, effects target molecules in the brain) tend to have similar
on the brain can occur within 30 seconds. Heroin, crack pharmacological effects. Hence, some sensible
cocaine, tobacco (nicotine), and cannabis (tetrahydro- predictions can be made about new compounds before
cannabinol) are all taken by one or other of these rapid they are used by human beings. Experimental studies of
routes. Absorption through the nasal mucosa, as with the dependence potential of old and new drugs are
powdered cocaine, is also surprisingly rapid. Taking the possible only in individuals who are already using drugs,
same drugs by mouth, so that they are only slowly so more population-based estimates of addictiveness (ie,
absorbed into the body, generally has a less powerful capture rates) have been developed for the more
pleasurable effect, although it can be longer lasting. commonly used drugs.11 These estimates suggest that
An essential feature of drugs of abuse is that they smoked tobacco is the most addictive commonly used
encourage repeated use. This tendency is driven by drug, with heroin and alcohol somewhat less so;
various factors and mechanisms. The special nature of psychedelics have a low addictive propensity.
drug experiences certainly has a role. Indeed, in the case
of hallucinogens (eg, lysergic acid diethylamide [LSD], Social
mescaline, etc) it might be the only factor that drives Drugs harm society in several ways—eg, through the
regular use, and such drugs are mostly used infrequently. various effects of intoxication, through damaging family
At the other extreme are drugs such as crack cocaine and and social life, and through the costs to systems of health
nicotine, which, for most users, induce powerful care, social care, and police. Drugs that lead to intense
dependence. Physical dependence or addiction involves intoxication are associated with huge costs in terms of
increasing tolerance (ie, progressively higher doses being accidental damage to the user, to others, and to property.
needed for the same effect), intense craving, and Alcohol intoxication, for instance, often leads to violent

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behaviour and is a common cause of car and other

Parameter
accidents. Many drugs cause major damage to the family,
either because of the effect of intoxication or because Physical harm One Acute
they distort the motivations of users, taking them away Two Chronic
from their families and into drug-related activities, Three Intravenous harm
including crime. Dependence Four Intensity of pleasure
Societal damage also occurs through the immense Five Psychological dependence
health-care costs of some drugs. Tobacco is estimated to Six Physical dependence
cause up to 40% of all hospital illness and 60% of Social harms Seven Intoxication
drug-related fatalities. Alcohol is involved in over half of Eight Other social harms
all visits to accident and emergency departments and Nine Health-care costs
orthopaedic admissions.12 However, these drugs also Table 1: Assessment parameters
generate tax revenue that can offset their health costs to
some extent. Intravenous drug delivery brings particular
problems in terms of blood-borne virus infections, Having established that this nine-parameter matrix
especially HIV and hepatitis, leading to the infection of worked well, we convened meetings of a second group
sexual partners as well as needle sharers. For drugs that of experts with a wider spread of expertise. These
have only recently become popular—eg, 3,4-methyl- experts had experience in one of the many areas of
enedioxy-N-methylamphetamine, better known as ecstasy addiction, ranging from chemistry, pharmacology, and
or MDMA—the longer-term health and social forensic science, through psychiatry and other medical
consequences can be estimated only from animal specialties, including epidemiology, as well as the legal
toxicology at present. Of course, the overall use of a drug and police services. The second set of assessments was
has a substantial bearing on the extent of social harm. done in a series of meetings run along delphic
principles, a new approach that is being used widely to
Assessment of harm optimise knowledge in areas where issues and effects
Table 1 shows the assessment matrix that we designed, are very broad and not amenable to precise
which includes all nine parameters of risk, created by measurements or experimental testing,14 and which is
dividing each of the three major categories of harm into becoming the standard method by which to develop
three subgroups, as described above. Participants were consensus in medical matters. Since delphic analysis
asked to score each substance for each of these nine incorporates the best knowledge of experts in diverse
parameters, using a four-point scale, with 0 being no risk, disciplines, it is ideally applicable to a complex variable
1 some, 2 moderate, and 3 extreme risk. For some analyses,
the scores for the three parameters for each category were Class in Misuse Comments
of Drugs Act
averaged to give a mean score for that category. For the
sake of discussion, an overall harm rating was obtained by Ecstasy A Essentially 3,4-methylenedioxy-N-methylamphetamine (MDMA)
taking the mean of all nine scores. 4-MTA A 4-methylthioamphetamine
The scoring procedure was piloted by members of the LSD A Lysergic acid diethylamide
panel of the Independent Inquiry into the Misuse of Cocaine A Includes crack cocaine
Drugs Act.13 Once refined through this piloting, an Heroin A Crude diamorphine
assessment questionnaire based on table 1, with additional Street methadone A Diverted prescribed methadone
guidance notes, was used. Two independent groups of Amphetamine B ..
experts were asked to do the ratings. The first was the Methylphenidate B eg, Ritalin (methylphenidate)
national group of consultant psychiatrists who were on Barbiturates B ..
the Royal College of Psychiatrists’ register as specialists in Buprenorphine C eg, Temgesic, Subutex
addiction. Replies were received and analysed from 29 of Benzodiazepines C eg, Valium (diazepam), Librium (chlordiazepoxide)
the 77 registered doctors who were asked to assess GHB C Gamma 4-hydroxybutyric acid
14 compounds—heroin, cocaine, alcohol, barbiturates, Anabolic steroids C ..
amphetamine, methadone, benzodiazepines, solvents, Cannabis C ..
buprenorphine, tobacco, ecstasy, cannabis, LSD, and Alcohol .. Not controlled if over 18 years in UK
steroids. Tobacco and alcohol were included because their Alkyl nitrites .. Not controlled
extensive use has provided reliable data on their risks and Ketamine .. Not controlled at the time of assessment; controlled as class C since
harms, providing familiar benchmarks against which the January, 2007
absolute harms of other drugs can be judged. However, Khat .. Not controlled
direct comparison of the scores for tobacco and alcohol Solvents .. Not controlled; sales restricted
with those of the other drugs is not possible since the fact Tobacco .. Not controlled if over 16 years in UK
that they are legal could affect their harms in various
Table 2: The 20 substances assessed, showing their current status under the Misuse of Drugs Act
ways, especially through easier availability.

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such as drug misuse and addiction. Initial scoring was

3·0 done independently by each participant, and the scores
Class for each individual parameter were then presented to
A the whole group for discussion, with a particular
B
C emphasis on elucidating the reasoning behind outlier
2·5
No class scores. Individuals were then invited to revise their
scores, if they wished, on any of the parameters, in the
light of this discussion, after which a final mean score
Mean score (from independent experts)

2·0 was calculated. The complexity of the process means

that only a few drugs can be assessed in a single
meeting, and four meetings were needed to complete
1·5
the process. The number of members taking part in the
scoring varied from eight to 16. However, the full range
of expertise was maintained in each assessment.
This second set of assessments covered the
1·0 14 substances considered by the psychiatrists plus, for
completeness, six other compounds (khat, 4-methylthio-
amphetamine [4-MTA], gamma 4-hydroxybutyric acid
0·5 [GHB], ketamine, methylphenidate, and alkyl nitrites),
some of which are not illegal, but for each of which there
have been reports of abuse (table 2). Participants were told
in advance which drugs were being covered at each
0·0
meeting to allow them to update their knowledge and
in

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Am aze e
et s

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es
at
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consider their opinion. Recent review articles5,6,7,15–18 were

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provided.
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Occasionally, individual experts were unable to give a

M
St

score for a particular parameter for a particular drug and

Figure 1: Mean harm scores for 20 substances these missing values were ignored in the analysis—ie,
Classification under the Misuse of Drugs Act, where appropriate, is shown by the colour of each bar. they were neither treated as zero nor given some
interpolated value. Data were analysed with the statistical
functions in Microsoft Excel and S-plus.

Results
3·0 Use of this risk assessment system proved straightforward
and practicable, both by questionnaire and in open delphic
2 1 discussion. Figure 1 shows the overall mean scores of the
2·5
3
independent expert group, averaged across all scorers,
4
5 plotted in rank order for all 20 substances. The classification
6
2·0 of each substance under the Misuse of Drugs Act is also
Psychiatrists

7 shown. Although the two substances with the highest

8 9
10
harm ratings (heroin and cocaine) are class A drugs, overall
1·5 there was a surprisingly poor correlation between drugs’
11
13 12 class according to the Misuse of Drugs Act and harm score.
14 Of both the eight substances that scored highest and the
1·0
eight that scored lowest, three were class A and two were
unclassified. Alcohol, ketamine, tobacco, and solvents (all
0·5 unclassified at the time of assessment) were ranked as
more harmful than LSD, ecstasy, and its variant 4-MTA (all
class A drugs). Indeed, the correlation between classification
0·0
0·0 0·5 1·0 1·5 2·0 2·5 3·0
by the Misuse of Drugs Act and harm rating was not
Independent experts
significant (Kendall’s rank correlation –0·18; p=0·25;
Spearman’s rank correlation –0·26, p=0·26). Of the
unclassified drugs, alcohol and ketamine were given
Figure 2: Correlation between mean scores from the independent experts especially high ratings. Interestingly, a very recent
and the specialist addiction psychiatrists
recommendation from the Advisory Council on the Misuse
1=heroin. 2=cocaine. 3=alcohol. 4=barbiturates. 5=amphetamine.
6=methadone. 7=benzodiazepines. 8=solvents. 9=buprenorphine. 10=tobacco. of Drugs that ketamine should be added to the Misuse of
11=ecstasy. 12=cannabis. 13=LSD. 14=steroids. Drugs Act (as a class C drug) has just been accepted.19

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We compared the overall mean scores (averaged across three (ie, the propensity for intravenous use) and nine
all nine parameters) for the psychiatrists with those of (health-care costs). Even if the scores for these two
the independent group for the 14 substances that were parameters were excluded from the analysis, the high
ranked by both groups (figure 2). The figure suggests ranking for such drugs persisted. Thus, drugs that can be
that the scores have some validity and that the process is administered intravenously were also judged to be very
robust, in that it generates similar results in the hands of harmful in many other respects.
rather different sets of experts.
Table 3 lists the independent group results for each of Discussion
the three subcategories of harm. The scores in each The results of this study do not provide justification for
category were averaged across all scorers and the the sharp A, B, or C divisions of the current classifications
substances are listed in rank order of harm, based on in the UK Misuse of Drugs Act. Distinct categorisation
their overall score. Many of the drugs were consistent in is, of course, convenient for setting of priorities for
their ranking across the three categories. Heroin, cocaine, policing, education, and social support, as well as to
barbiturates, and street methadone were in the top five determine sentencing for possession or dealing. But
places for all categories of harm, whereas khat, alkyl neither the rank ordering of drugs nor their segregation
nitrites, and ecstasy were in the bottom five places for all. into groups in the Misuse of Drugs Act classification is
Some drugs differed substantially in their harm ratings supported by the more complete assessment of harm
across the three categories. For instance, cannabis was described here. Sharply defined categories in any ranking
ranked low for physical harm but somewhat higher for system are essentially arbitrary unless there are obvious
dependence and harm to family and community. discontinuities in the full set of scores. Figure 1 shows
Anabolic steroids were ranked high for physical harm only a hint of such a transition in the spectrum of harm,
but low for dependence. Tobacco was high for dependence in the small step in the very middle of the distribution,
but distinctly lower for social harms, because it scored between buprenorphine and cannabis. Interestingly,
low on intoxication. Tobacco’s mean score for physical alcohol and tobacco are both in the top ten, higher-harm
harm was also modest, since the ratings for acute harm group. There is a rapidly accelerating harm value from
and potential for intravenous use were low, although the alcohol upwards. So, if a three-category classification
value for chronic harm was, unsurprisingly, very high. were to be retained, one possible interpretation of our
Drugs that can be administered by the intravenous findings is that drugs with harm scores equal to that of
route were generally ranked high, not solely because they alcohol and above might be class A, cannabis and those
were assigned exceptionally high scores for parameter below might be class C, and drugs in between might be

Physical harm Dependence Social harm

Mean Acute Chronic Intravenous Mean Pleasure Psychological Physical Mean Intoxication Social Health-care
dependence dependence harm costs
Heroin 2·78 2·8 2·5 3·0 3·00 3·0 3·0 3·0 2·54 1·6 3·0 3·0
Cocaine 2·33 2·0 2·0 3·0 2·39 3·0 2·8 1·3 2·17 1·8 2·5 2·3
Barbiturates 2·23 2·3 1·9 2·5 2·01 2·0 2·2 1·8 2·00 2·4 1·9 1·7
Street methadone 1·86 2·5 1·7 1·4 2·08 1·8 2·3 2·3 1·87 1·6 1·9 2·0
Alcohol 1·40 1·9 2·4 NA 1·93 2·3 1·9 1·6 2·21 2·2 2·4 2·1
Ketamine 2·00 2·1 1·7 2·1 1·54 1·9 1·7 1·0 1·69 2·0 1·5 1·5
Benzodiazepines 1·63 1·5 1·7 1·8 1·83 1·7 2·1 1·8 1·65 2·0 1·5 1·5
Amphetamine 1·81 1·3 1·8 2·4 1·67 2·0 1·9 1·1 1·50 1·4 1·5 1·6
Tobacco 1·24 0·9 2·9 0 2·21 2·3 2·6 1·8 1·42 0·8 1·1 2·4
Buprenorphine 1·60 1·2 1·3 2·3 1·64 2·0 1·5 1·5 1·49 1·6 1·5 1·4
Cannabis 0·99 0·9 2·1 0 1·51 1·9 1·7 0·8 1·50 1·7 1·3 1·5
Solvents 1·28 2·1 1·7 0 1·01 1·7 1·2 0·1 1·52 1·9 1·5 1·2
4-MTA 1·44 2·2 2·1 0 1·30 1·0 1·7 0·8 1·06 1·2 1·0 1·0
LSD 1·13 1·7 1·4 0·3 1·23 2·2 1·1 0·3 1·32 1·6 1·3 1·1
Methylphenidate 1·32 1·2 1·3 1·6 1·25 1·4 1·3 1·0 0·97 1·1 0·8 1·1
Anabolic steroids 1·45 0·8 2·0 1·7 0·88 1·1 0·8 0·8 1·13 1·3 0·8 1·3
GHB 0·86 1·4 1·2 0 1·19 1·4 1·1 1·1 1·30 1·4 1·3 1·2
Ecstasy 1·05 1·6 1·6 0 1·13 1·5 1·2 0·7 1·09 1·2 1·0 1·1
Alkyl nitrites 0·93 1·6 0·9 0·3 0·87 1·6 0·7 0·3 0·97 0·8 0·7 1·4
Khat 0·50 0·3 1·2 0 1·04 1·6 1·2 0·3 0·85 0·7 1·1 0·8

Table 3: Mean independent group scores in each of the three categories of harm, for 20 substances, ranked by their overall score, and mean scores for each of the three subscales

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class B. In that case, it is salutary to see that alcohol and multi-criteria decision analysis,20 could be used to take
tobacco—the most widely used unclassified sub- account of variation of ranking across different
stances—would have harm ratings comparable with parameters of harm. Despite these reservations about
class A and B illegal drugs, respectively. the interpretation of integrated scores and the need for
Participants were asked to assess the harm of drugs further consideration of the weighting of parameters of
administered in the form that they are normally used. In harm, we were greatly encouraged by the general
a few cases, the harms caused by a particular drug could consistency of scores across scorers and across
not be completely isolated from interfering factors parameters of harm for most drugs.
associated with the particular style of use. For example, Our findings raise questions about the validity of the
cannabis is commonly smoked as a mixture with tobacco, current Misuse of Drugs Act classification, despite the
which might have raised its scores for physical harm and fact that it is nominally based on an assessment of risk to
dependence, among other factors. There is a further users and society. The discrepancies between our findings
degree of uncertainty resulting from polydrug use, and current classifications are especially striking in
especially in the so-called recreational group of drugs relation to psychedelic-type drugs. Our results also
that includes GHB, ketamine, ecstasy, and alcohol, for emphasise that the exclusion of alcohol and tobacco from
which adverse effects could be attributed mainly to one the Misuse of Drugs Act is, from a scientific perspective,
of the components of commonly used mixtures. Crack arbitrary. We saw no clear distinction between socially
cocaine is generally deemed to be more dangerous than acceptable and illicit substances. The fact that the two
powdered cocaine, but they were not considered most widely used legal drugs lie in the upper half of the
separately in this study. Similarly, the scores for the ranking of harm is surely important information that
benzodiazepines might have been biased in the direction should be taken into account in public debate on illegal
of the most abused drugs, especially temazepam. drug use. Discussions based on a formal assessment of
Individual scoring for particular benzodiazepines and for harm rather than on prejudice and assumptions might
the various forms in which other drugs are used would help society to engage in a more rational debate about the
be more appropriate should this or any other system of relative risks and harms of drugs.
harm classification be used in a formal setting. We believe that a system of classification like ours, based
In view of the small numbers of independent scores, on the scoring of harms by experts, on the basis of scientific
we did not think that estimation of correlations between evidence, has much to commend it. Our approach provides
the nine parameters was legitimate. There is quite likely a comprehensive and transparent process for assessment
to be some redundancy—ie, the nine parameters might of the danger of drugs, and builds on the approach to this
not represent nine independent measures of risk. In issue developed in earlier publications5–8,11,12,21,22 but covers
much the same way, the principal components of the more parameters of harm and more drugs, as well as using
parameters were not extracted, partly because we thought the delphic approach, with a range of experts. The system
that there were insufficient data and partly because is rigorous and transparent, and involves a formal,
reduction of the number of parameters to a core group quantitative assessment of several aspects of harm. It can
might not be appropriate, at least until further assessment easily be reapplied as knowledge advances. We note that a
panels have independently validated the entire system. numerical system has also been described by MacDonald
Our analysis gave equal weight to each parameter of and colleagues23 to assess the population harm of drug use,
harm, and individual scores have simply been averaged. an approach that is complementary to the scheme
Such a procedure would not give a valid indication of described here, but as yet has not been applied to specific
harm for a drug that has extreme acute toxicity, such as drugs. Other organisations (eg, the European Monitoring
the designer drug contaminant MPTP (1-methyl 4-phenyl Centre for Drugs and Drug Addiction24 and the CAM
1,2,3,6-tetrahydropyridine), a single dose of which can committee of the Dutch government25) are currently
damage the substantia nigra of the basal ganglia so exploring other risk assessment systems, some of which
severely that it induces an extreme form of Parkinson’s are also numerically based. Other systems use delphic
disease. Indeed, this simple method of integrating scores methodology, although none uses such a comprehensive
might not deal adequately with any substance that is set of risk parameters and no other has reported on such a
extremely harmful in only one respect. Take tobacco, for wide range of drugs as our method. We believe that our
instance. Smoking tobacco beyond the age of 30 years system could be developed to aid in decision-making by
reduces life expectancy by an average of up to 10 years,9 regulatory bodies—eg, the UK’s Advisory Council on the
and it is the commonest cause of drug-related deaths, Misuse of Drugs and the European Medicines Evaluation
placing a huge burden on health services. However, Agency—to provide an evidence-based approach to drug
tobacco’s short-term consequences and social effects are classification.
unexceptional. Of course, the weighting of individual Contributors
parameters could be varied to emphasise one facet of All authors contributed to the study design, analysis, and writing of the
risk or another, depending on the importance attached manuscript. All authors saw and approved the final version of the
manuscript.
to each. Other procedural mechanisms, such as those of

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Conflict of interest statement 12 Academy of Medical Sciences. Calling time: the nation’s drinking as
We declare that we have no conflict of interest. a major health issue. London: Academy of Medical Sciences, 2004.
13 Drugs and the Law. Report of the Independent Inquiry into the
Acknowledgments Misuse of Drugs Act 1971. London: The Police Foundation, 2000.
Some of the ideas developed in this paper arose out of discussion at
14 Turoff M. The design of a policy delphi. Technological Forecasting
workshops organised by the Beckley Foundation, to whom we are and Social Change 1970; 2: 149–71.
grateful. We thank David Spiegelhalter of the MRC Biostatistics Unit for
15 Corkery JM. Drug seizures and offender statistics. UK 2000.
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