US drug policy does not align with experts' rankings of drug harms: a multi-criteria decision analysis

Background United States drug policy is primarily based on the Controlled Substances Act of 1970 and largely contradicts scientific evidence about how to mitigate drugs' harms. Expert consensus on drug harms could inform policy that improves the health of people who use drugs while reducing negative societal impacts of drug use. Therefore, this study adapted and extended the relevant 2010 United Kingdom multi-criteria decision analysis, rating drug harms by criteria comprising health and social impacts to people who use drugs and their families, communities, and society.Methods Seventeen experts on drug use in the US, including three with lived experience of drug use and recovery, assessed 19 drugs across 18 criteria. Drugs were scored from 0 to 100 points on each criterion. Then, criteria were weighted to represent the experts' view of their relative importance, and each drug was assigned an overall harm score. We also created a numerical rating to represent Controlled Substances Act-defined harm.Results Fentanyl (scoring 90), methamphetamine (84), crack (83), and heroin (82) were the most harmful drugs. Cannabis (32) ranked in the middle, and mushrooms (3) were the least harmful. Drug-specific mortality and economic cost were the largest overall contributors to harm, while environmental damage was the smallest. The correlation between Controlled Substances Act-defined harm and experts' harm ratings was - 0.26.Conclusions These findings add to the growing international literature highlighting how drug policy contradicts expert assessments of drug harms across nations. To reduce these harms, public health strategies informed by evidence and expert input should be prioritized over punitive approaches.