Questioning the method and utility of ranking drug harms in drug policy [Commentary] (2011)

In a 2010 Lancet paper Nutt et al. propose a model for evaluating and ranking drug harms, building on earlier work by incorporating multi criteria decision analysis. It is argued that problems arise in modelling drug harms using rankable single figure indices when determinants of harm reflect pharmacology translated through a complex prism of social and behavioural variables, in turn influenced by a range of policy environments. The delphic methodolgy used is highly vulnerable to subjective judgements and even the more robust measures, such as drug related death and dependence, can be understood as socially constructed. The failure of the model to dissaggregate drug use harms from those related to the policy environment is also highlighted. Beyond these methodological challenges the utility of single figure index harm rankings is questioned, specifically their role in increasingly redundant legal frameworks utilising a harm-based hierarchy of punitive sanctions. If analysis is to include the capacity to capture the complexity relating to drug using behaviours and environments; specific personal and social risks for particular using populations; and the broader socio-cultural context to contemporary intoxication, there will need to be acceptance that analysis of the various harm vectors must remain separate - the complexity of such analysis is not something that can or should be over generalised to suit political discourse or outdated legal frameworks.