![]() These differing results are influenced by a wide range of contextual factors, including drug availability, drug prices, drug purity, use levels, differences in legal status and the composition of the expert panels. All these studies consistently ranked alcohol as the most harmful drug, although also yielded somewhat different results for other drugs, highlighting the importance of country- and region-specific drug harm evaluations. To date, MCDA has been used to rank drug harms within the United Kingdom ( Nutt et al., 2010), Australia ( Bonomo et al., 2019) and Europe ( van Amsterdam et al., 2015b). A previously developed MCDA drug harm framework provides a robust method of comparing harms from different drugs ( Nutt et al., 2007) and considers harms to both individuals and others. This method has also been used to assess drug policy options ( Wilkins et al., 2022). ![]() This group decision-making technique, when applied to drug harm, utilises diverse panels of experts, who collaborate to scale and weight predetermined harm criteria. One way to manage this complexity is through the use of a multi-criteria decision analysis (MCDA) approach ( Phillips, 2017) applied in a Decision Conferencing setting ( Phillips and Bana e Costa, 2007). Additionally, systematic data on particular drugs or forms of harm are scarce, making it difficult to consistently measure markers of harm ( Crossin et al., 2022). The relative impact of these harms is likely to vary from one location to another due to variables such as use patterns, legal frameworks and cultural values. There is a complex interrelationship between harms for example, drug-related convictions and other related harms tend to further disadvantage vulnerable individuals and communities, and the illegality of some drugs can add to any harms accruing from merely using the drug ( Fergusson et al., 2003 Katikireddi et al., 2017). Harms can be categorised as those that impact on individuals who use a drug, and those which impact upon others, such as families, communities or broader society. ![]() The overall harm arising from use of a drug depends upon intrinsic factors such as its pharmacological and pharmacodynamic properties ( MacCoun and Reuter, 2001 Nutt et al., 2007) and extrinsic factors including individual, social, cultural, political and legal factors ( Rhodes, 2009). For policies that effectively reduce drug harm, however, it is crucial to first understand the relative harm attributable to different drugs, and the profile and distribution of those harms ( Bonomo et al., 2019). Considering limitations in the ability of supply-side interventions to curb these trends ( Cunningham et al., 2018 United Nations Office on Drugs and Crime, 2019), there is a need to consider policy reform approaches that collectively prioritise harm minimisation, and provide a balance of supply, demand and harm reduction interventions. In addition, global alcohol use continues to be a significant source of harm and is estimated to contribute to nearly 3 million deaths globally every year ( Griswold et al., 2018). International drug markets are evolving rapidly, and the emergence of new methods of distribution, in addition to the introduction of novel psychoactive substances, has contributed to the highest global drug supply on record ( Bonomo et al., 2019 United Nations Office on Drugs and Crime, 2022). The harms arising from the use of psychoactive drugs, including legal drugs such as alcohol and tobacco, are complex and significant.
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