Week 8 Reading: Chapter 3 (How can we Measure the Harms Done by Drug)

Question 1

Evidence-Based Comparison of Harms

Answer 1

• Misuse of drugs law in UK 1971 = drugs put into three classes A,B and C
  • Council set up to advise what class a given drug should be put in (the ACMD)
  • Problem is the class system is largely static with no movement of drugs between classes according to evidence or even advice of the advisory council. i.e. it’s not evidence based

-This gives the public the wrong information about drug harms and undermines the effectiveness of messages from the government surrounding drugs i.e. someone is not going to listen to an actually important message if the entire system the government uses to class drugs is so obviously flawed - they lose credibility.

Question 2

What should a drug classing system ideally be like? What challenges present when trying to achieve this?

Answer 2

• A drug classing system should be transparent (so people trust it), evidence based and flexible (drugs can move according to new information).
  • Measuring drug harms is complicated as there is so many different factors to consider e.g. chronic illness, death, mental health problems, social problems like crime and violence etc. -> how do we think about these various harms at the same time? (take a holistic approach to drugs)

Question 3

How many types of harm where identified by david nutt? What two overarching categories do these fall into ?

Answer 3

16
-Harm to users (individual level) = 9
-Harm to others (population level) =7

Question 4

Types of harm to users: drug specific mortality

Answer 4

-What is the difference between the effective dose (produces psychoactive effects) and the lethal dose? This gives a safety ratio

-In other words how likely is someone to die from poisoning due to the drug (overdose)

Question 5

Types of harm to users: drug related mortality

Answer 5

-Deaths from chronic illnesses, such as cancers, caused by drug-taking and deaths from associated behaviours and activities e.g. injecting putting users at risk of HIV/ aids.

-Can sometimes overlap with drug-specific mortality i.e. overdose causes death but harms associated with use but individual more at risk of this (cardiovascular illness).

Question 6

Types of harm to users: Drug-specific harm

Answer 6

-Any physical damage (short of death) specifically caused by the drug e.g. alcohol-related cirrhosis.

Question 7

Types of harm to users: Drug-related harm

Answer 7

Damage short of death from drug related activities and behaviours e.g. viruses and infections, non-fatal road accidents

Question 8

Types of harm to users: dependence

Question 9

Types of harm to users: drug-related impairment of mental functioning

Answer 9

-Psychological effects that continue once the drug has left the body

-Heavy drug use can be associated with psychotic symptoms = depression, memory loss, increased aggression, anhedonia (inability to feel pleasure).

-Addiction -> depression

Question 10

Types of harm to users; Drug-specific impairment of mental functioning

Answer 10

-Intoxication impairs judgment which can lead to risk behaviours like unprotected sex as well as drunk driving.

Question 11

Types of harms to users: Drug-specific impairment of mental functioning

Answer 11

Intoxication impairs judgment which can lead to risk behaviours like unprotected sex as well as drunk driving.

Question 12

Types of harm to users: Loss of Tangibles

Answer 12

• Job
  -Income
  -Possessions
  -Home

Loss of due to drugs

Question 13

Types of harm to users: Loss of relationships

Answer 13

• Lose friends due to behaviour while intoxicated (aggressive/ reclusive)

-They might engage in compulsive behaviours like stealing from friends to fund drug habit.

Question 14

Types of harm to others: Injury

Answer 14

Impair motor control + judgment therefore increasing likelihood of accidents that damage someone else e.g. road.

Question 15

Types of harm to others: Crime

Answer 15

Two categories :
-Acquisitive crime to fund a drug habit
-Crime committed when judgment is impaired while under influence (burglary and vandalism).

Question 16

Types of harm to others: Economic cost

Answer 16

-Workdays lost due to use

-Amount of police time spent dealing with drugs/ associated crime
Cost to health services

Question 17

Types of harms to others: Impact on family life

Answer 17

-Loss of relationships
-Behaviour (particularly aggression or compulsivity) may influence family members

Question 18

Types of harms to others: International damage

Answer 18

-The drug industry is global
-Huge collateral damage of the war on drugs, the brutality of the international drug barons
-Carbon emissions + other environmental effects due to drug manufacturers and measures taken against them.

Question 19

Types of harms to others: Environmental damage

Answer 19

-Drug production can pollute local areas with toxic or flammable chemical
-Needles + broken bottles littering local parks -> make no go areas for children
-Noisy + aggressive behaviour degrades the environment
- Decline in reputation of the community

Question 20

Types of harms to others: Decline in reputation of the community

Answer 20

• Can stigmatize particular social groups and turn neighbourhoods into no-go zones.
• Certain drugs, like crack are notorious for this.

Question 21

Multi-Criteria Decision Analysis

Answer 21

• MCDA is a technique used in situations where a decision needs to take into account different sorts of information and where there are so many dimensions that conclusions cannot easily be drawn from simple discussion.
• MDCA breaks down an issue into different criteria and compares those criteria with each other to assess relative importance (criteria can hold both objective and subjective value judgements).

Question 22

Panel of experts

Answer 22

• To review the 16 harms

-5 experts in addiction + 2 experts in drug issues relating to young people, 2 chemists, another 5 experts from a range of backgrounds.

Question 23

Which drugs did the expert panel consider?

Answer 23

-Stimulants
-Depressants
-Opioids
-Empathogens and psychedelics

Question 24

Rating the drugs

Answer 24

• Rated on a 0-100 scale for drug related mortality using MCDA and also on each of the other 16 criteria
• Each drug was given a position on the scale which was reached by debate among the experts, considering research/ evidence and then corroborating scores
• There were some issues with a lack of objective data in areas e.g. social harms -> here debate among experts was the primary decision approach.

Question 25

Weighting the Scores

Answer 25

• Have ratings on the scale for each of the 16 criteria now need to weight them against each other
• 2 things to consider
  ○ How big was the difference between 0-100
  ○ What was the importance of each criteria
• The process of changing weights in a model once it has been constructed is called sensitivity analysis, this is a big advantage of MCDA (multi-criteria decision analysis)

Question 26

Results

Answer 26

• Each drug gets a final score out of 100 once all 16 criteria are considered.
• Really good graph in book for this but top is alcohol: ranked fourth most harmful to self and most harmful to others but legal!
• At the bottom end there is ecstasy, LSD and mushrooms all class A
• When compare legal class and overall ranking only a correlation of 0.04 -> drug policy is not evidence based!

-Repetitions of approach in various countries (Europe, Canada, Australia) have yielded similar rankings

Question 27

Limitation to Model

Answer 27

• No scoring of benefits
• Alcohol + tobacco for example bring in money and create jobs which can help offset their economic costs to a certain extent
• Cannot distinguish between harms of the drugs and harms related to its legality e.g. overdose risk for heroin largely due to not getting a legal/ clean supply
• Most people are polydrug users and this model isolates risks of single drugs
• Different patterns of use and methods of taking drugs not considered i.e. prescription versus non-prescription. Addicts versus non-addicts.

Question 28

Reviewing Ketamine

Answer 28

• Ketamine is a powerful anaesthetic and safe because it depresses breathing very little and doesn’t stop the gag reflex BUT it is rarely used in medicine because of psychoactive effects.
• Commonly referred as horse tranquillizer as used on animals.
• Started to be used recreationally in the dance scene which caused concern and got put into class C (mainly due to poly drug use).
• Increase in people seeking help for ketamine dependence and an increase in young people (mainly men) seeking help for urinary tract problems related to ketamine use -> peeing + blood in urine (not entirely sure why the drug has this effect but it appears to be robust).

-Nutt would probably rate it higher now