1. Psychoactive drugs: modelling their harm and policies for their control Professor Lawrence Phillips London School of Economics & Political Science and Facilitations Ltd Operational Research Society Criminal Justice Special Interest Group 18 November 2015

2. March 2007 Nutt, D., King, L. A., Saulsbury, W., & Blakemore, C. (2007). Development of a rational scale to assess the harm of drugs of potential misuse. [Journal]. The Lancet, 369, 1047- 1053. 2

3. March & June 2009 ▫Medical Research Council and Home Office co-sponsor research project ▫Advisory Council on the Misuse of Drugs, (ACMD), David Nutt as Chair, meets to develop an MCDA model and to test its potential for evaluating drug harms May 2007 ▫Blakemore, Nutt and Phillips meet for first time ▫Phillips explains MCDA, multi-criteria decision analysis, as a possible approach to modelling drug harms ▫We draft research project proposal 3

4. July 2009 4

5. October 2009 5

6. January 2010 ▫Nutt sets up the Independent Scientific Committee on Drugs ISCD June 2010 ▫ISCD builds on the ACMD work by completing the evaluation of harms; this is reported here July 2010 ▫ACMD publishes the MCDA framework developed in 2009 ▫http://www.homeoffice.gov.uk/publications/drugs/acmd1/ACMD- multi-criteria-reporthttp://www.homeoffice.gov.uk/publications/drugs/acmd1/ACMD- multi-criteria-report 6

7. Nutt, D. J., King, L. A., Phillips, L. D., & on behalf of the Independent Scientific Committee on Drugs. (2010). Drug harms in the UK: a multicriteria decision analysis. The Lancet, 376(1558-65). 7

8. A one-to-three-day workshop To resolve important issues of concern Attended by key players who represent the diversity of perspectives on the issues Facilitated by an impartial specialist in group processes & decision analysis Using a requisite (just-good-enough) model created on-the-spot to help provide structure to thinking Decision Conference 8

9. Decision conference + MCDA A methodology for a group of key players to appraise options on multiple criteria, and combine them into one overall appraisal MCDA converts all input evaluations of decision outcomes into the common currency of value added 9

10. MCDA provides a way to compare apples and oranges, provided there is a context that establishes added value. For the ISCD, it was negative value: physical, psychological and social harm 10

11. ProblemObjectivesAlternativesConsequencesTrade-offsUncertainty Risk attitude Linked decisions 11 PrOACT-URL framework

12. Methods Study design ▫16 harm criteria developed by ACMD  ▫20 drugs ▫ISCD members plus 2 external experts ▫Meeting facilitated as a decision conference 12

13. The 20 drugs HeroinCrackCocaineAlcohol TobaccoAmphetamineMephedroneBuprenorphine BenzodiazepinesCannabis Anabolic Steroids Ecstasy KetamineLSDMushrooms Methylamphet- amine KhatButaneMethadoneGHB 13

14. Scoring the drugs The most harmful drug on each criterion was scored at 100. All other drugs were scored relative to that drug. E.g., a drug considered half as harmful was given a score of 50. This creates a unique ratio scale for each criterion. 100 ┬ Most harm ┤ 80 ┤ ┤ 60 ┤ ┤ 40 ┤ ┤ 20 ┤ ┤ 0 ┴ No harm 14

15. 15

16. Weighting the criteria Some criteria represent more harm than others. Swing-weights equate the units of harm on all the criteria: the swing in harm from the ‘no harm’ point to the ‘most harmful’ drug. The group considered this question to compare the levels of ‘most harm’ on the criteria: ▫“How big is the difference in harm and how much do you care about that difference?” 100 ┬ Most harm ┤ 80 ┤ ┤ 60 ┤ ┤ 40 ┤ ┤ 20 ┤ ┤ 0 ┴ No harm 16

17. ISCD UK results 2010 17

18. 18 European replication May 2013

19. UK 2010 vs. Europe 2013 Europe UK r = 0.993 19 Supports the reliability of judgements

20. Correlations of ISCD scores with......van Amsterdam population...van Amsterdam individual linear r = 0.84 Reference: van Amsterdam, J. G. C., Opperhuizen, A., Koeter, M., & van den Brink, W. (2010). Ranking the harm of alcohol, tobacco and illicit drugs for the individual and the population. European Addiction Research, 16, 202-207. 20

21. Correlation of UK Drugs Act classification with ISCD results linear r = 0.04 without the un- classified drugs: linear r = 0.38 21 U 211

22. Harm to Users Harm to Others Alcohol  22

23. Conclusions High correlations among the UK, EU and Dutch studies establish the validity of the MCDA approach to modelling the harm of drugs. The improved scoring and weighting in MCDA increases the differentiation between most and least harmful drugs. The present UK drug classification system is not simply based on considerations of harm. Targeting alcohol harms is a valid and necessary public health strategy. 23

24. DrugScience 18-19 July 2013 24

25. MCDA for 12 nicotine products Cigarettes Manufactured and hand-rolled cigarettes in which the tobacco is wrapped in paper. CigarsSmoked cigars: rolled tobacco leaf. Small cigars Used like a cigarette but wrapped in tobacco leaf (a product largely limited to the USA but widely used there). PipesA tube with a small bowl at one end for smoking tobacco. Water pipeWhere tobacco smoke is bubbled through water. Smokeless refined Non-snus (and other) smokeless refined tobacco products used orally, including leaf chewing tobacco and snuff. Smokeless unrefined Non-snus (and other) smokeless unrefined tobacco products used orally, including leaf chewing tobacco and snuff. SnusA low nitrosamine and non-fermented smokeless tobacco product. ENDSElectronic Nicotine Delivery System products, e.g. e-cigarettes. Oral productsOrally-available nicotine products. PatchDermal nicotine delivery products. Nasal spraysNasal nicotine delivery products. 255

26. ISCD results 17-18 July 2013 26

27. DrugScience 10 September 2015 27

28. Context DrugScience collaboration ▫Frisch Centre and SIRUS - the Norwegian Institute for Alcohol and Drug Research (Ole Rogeberg is the lead researcher) ▫Funded by the Norwegian Research Council. Purpose ▫Develop an analytic framework for describing, measuring, assessing and discussing drug policy Decision conference ▫10-11 September in London ▫Develop MCDA model for comparative analysis of different policies 28

29. Four policy options to test MCDA model Options constructed from combinations of policy features ▫Production ▫Sale/distribution ▫Purchase ▫Purchase volume (for legal users) ▫Possession ▫Use Options ▫Absolute Prohibition ▫State Control ▫Decriminalisation ▫Free Market 29

30. Seven impacts ▫Health ▫Social ▫Political ▫Public ▫Crime ▫Economic ▫Costs 27 Policy criteria (e.g. Health) ▫Harm to user ▫Harm to others ▫More harmful substance ▫Encourages treatment ▫Product quality The drug policy MCDA model 30

31. State control most preferred Key impacts ▫Health (harm to user) ▫Public (protects children, young & vulnerable) ▫Crime (like Free Mkt) Free market least preferred Results for alcohol 31

32. State control vs. Free market State control better Free market better 32

33. State control vs. Decriminalisation State control better Decriminalisation better 33

34. State control vs. Absolute prohibition State control better Prohibition better 34

35. Next steps 1.Decision Conference, 20-21 January 2016 2.Test on other substances 3.Add criteria that are substance specific (ketamine) 4.Delete criteria that don’t discriminate very well 5.Refine policy options 6.Test with other groups of experts 7.Use model to compare policies of other countries 8.….. 35

36. A guide to further reading CRC Press, 2014. Overview of B-R assessment across the R&D spectrum. Chapter 5 describes methods & applications, including MCDA. Dodgson, J., Spackman, M., Pearman, A., & Phillips, L. (2000). Multi-Criteria Analysis: A Manual. London: Department of the Environment, Transport and the Regions, republished 2009 by the Department for Communities and Local Government. Download free at http://eprints.lse.ac.uk/12761. MCDA is described in Chapter 6. http://eprints.lse.ac.uk/12761 36 Harvard University Press, 1992. Shows how to articulate values and make wise decisions.