Table

ASSESSMENT PARAMETERS

Category of harm Parameter

Physical Harm

1

Acute

2

Chronic

3

IV harm

Dependence

4

Intensity of pleasure

5

Psychological dependence

6

Physical dependence

Social Harms

7

Intoxication

8

Other social harms

9

Healthcare costs

Participants were asked to score each substance for each of these nine parameters, using a four-point scale, with 0 being no risk, 1 some, 2 moderate and 3 extreme risk. For some analyses [eg Table 3], the scores for the three parameters for each category were averaged to give a mean score for that category. An overall harm rating was obtained by taking the mean of all nine scores.

The scoring procedure was piloted by members of the panel of the Independent Inquiry into the MDAct (the Runciman Committee 2000; Ref 5). Once refined through this piloting, an assessment form based on Table 1, with additional guidance notes, was used. Two independent groups of experts were asked to perform the ratings. The first was the national group of consultant psychiatrists who were on the Royal College of Psychiatrists' register as specialists in addiction. Replies were received and analysed from 29 of the 77 registered doctors canvassed on 14 compounds (those listed in legend to fig 2). Tobacco (cigarettes) and alcohol were also included because their extensive use has provided reliable data on their risks and harms: hence, they provide familiar benchmarks against which the absolute harms of other drugs can be judged.

Following this assessment a second group was convened that also assessed these 14 substances and for completeness an additional six abused compounds (khat, 4MTA, GHB, ketamine, methylphenidate, alky nitrites (Table 2)). This group was made up of individuals with a wide range of expertise in addiction— ranging from the forensic science service through to general practitioners and epidemiologists and included law enforcement officers. Scoring was done independently and individual scores were then presented to the whole group for a "Delphic" type discussion. Individuals were allowed to revise their score on any of the parameters in the light of this discussion, after which a final mean score was calculated. The number of members taking part in the scoring varied from eight to 16 over the course of several meetings.

Table 2

THE 20 SUBSTANCES ASSESSED SHOWING THEIR CURRENT STATUS UNDER THE MDACT AND THE MISUSE OF DRUGS REGULATIONS

Substance

Class in Act

Schedule in Regulations

Comments

Ecstasy

A

1

Essentially MDMA

4-MTA

A

1

4-methythioamphetamine

LSD

A

1

Lysergide

Cocaine

A

2

includes crack cocaine

Heroin

A

2

Crude diamorphine

Street Methadone

A

2

Amphetamine

B

2

Methylphenidate

B

2

eg "Ritalin"

Barbiturates

B

most in 3

Buprenorphine

C

3

Pending move to Class B

Benzodiazepines

C

most in 4(1)

GHB

C

4(1)

4-hydroxybutyric acid

Anabolic Steroids

C

4(2)

Cannabis

C

1

Alcohol

-

-

Not controlled

Alkyl Nitrites

-

-

Not controlled

Ketamine

-

-

Not controlled, but moving to class C in 2006

Khat

-

-

Not controlled

Solvents

-

-

Not controlled

Tobacco

-

-

Not controlled

Results and Discussion

Use of this risk assessment system proved straightforward and practicable. The overall mean scores by the independent group averaged across all scorers, are plotted in rank order for all 20 substances in Figure 1. The classification of each substance under the MDAct is also shown by the shading of the bars of the histogram. Although the two substances with the highest harm ratings (heroin and cocaine) are Class A drugs, overall there is a surprisingly poor correlation between MDAct Class and harm score. Of both the 8 highest and the 8 lowest substances in the ranking of harm, three are Class A and two are unclassified. Alcohol, ketamine, tobacco and solvents (all unclassified) were ranked as more harmful than LSD, ecstasy and its variant 4-MTA (all Class A). Indeed, the correlation between MDAct classification and harm rating was not statistically significant (Kendall's rank-correlation = -0.18; 2P = 0.25. Spearman's rank-correlation = -0.26; 2P = 0.26). Interestingly, of the unclassified drugs, alcohol and ketamine were rated particularly high, and the Advisory Council on the Misuse of Drugs has recently recommended that ketamine should be added to the MDAct (as Class C) [Ref 5A].

Figure 2 compares the overall mean scores (averaged across all nine parameters) for the psychiatrists with those of the independent group for the 14 substances that were ranked by both groups (see legend to Fig.2). The average scores for the two groups were remarkably well correlated (r = 0.892; t = 6.8; P < 0.001) which suggests the scores and process have validity.

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