Language

English

Publication Date

12-31-2025

Journal

Harm Reduction Journal

DOI

10.1186/s12954-025-01390-x

PMID

41476288

PMCID

PMC12866486

PubMedCentral® Posted Date

12-31-2025

PubMedCentral® Full Text Version

Post-print

Abstract

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.

Keywords

Humans, United States, Decision Support Techniques, Substance-Related Disorders, Illicit Drugs, Health Policy, Drug and Narcotic Control, Harm Reduction

Published Open-Access

yes

Download

Share

COinS
 
 

To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.