Proposal Seeks to Improve Assessment of Drug Risks

A drug policy researcher is proposing a suite of changes to overhaul the Multi-Criteria Drug Harm Scale (MCDHS), which informs drug policies across Europe. The changes focus on addressing use and abuse separately, collecting input from a broader range of stakeholders, and targeting substance-specific experts for drug review panels.

“The MCDHS, also known as the Multi-Criteria Decision Analysis of Drug Harms, is a valuable tool that allows for informed decision making about substances that can have serious consequences for health and well-being on a national scale,” says Veljko Dubljevic, author of a paper describing the proposals. “But there is significant room for improvement.” Dubljevic is an assistant professor of ethics at North Carolina State University and an affiliate of NC State’s Science, Technology & Society program

“My proposals would allow for a deeper assessment of the harms associated with substances such as opioids, cannabis, tobacco and stimulants,” Dubljevic says. “And this is an approach that I think the United States should adopt, rather than relying largely on industry-funded research.”

The MCDHS has been around for about a decade, and draws on a panel of experts in psychiatry, pharmacology and addiction to rank a drug’s risk of causing harm in three areas: physical health effects, potential for dependence, and social harm. To date, the MCDHS has been used in the European Union, the United Kingdom, the Netherlands and Norway.

The first of three changes Dubljevic is proposing to the MCDHS is to dissociate the harms of a drug’s use from the harms of its abuse.

“The risks of drinking a glass of wine on the weekend are different from the risks associated with heavy drinking,” Dubljevic says. “The same is true for the proper use of a prescription drug versus chronic, off-label use. It’s important to assess the risks of drug use and drug abuse separately, and to give each drug two ratings: one for proper use and one for abuse.”

The second proposal is to incorporate input from people on the front lines of drug use. Specifically, Dubljevic calls for panels to incorporate input from people who use drugs, pharmacists and general medical practitioners.

“This local expertise can provide valuable perspectives that allow for a more robust understanding of a substance’s potential for addiction or social harms,” Dubljevic says.

The third proposal is to eschew one-size-fits-all expert panels and instead form panels with substance-specific expertise.

“For example, individuals with expertise in prescription opioids are likely not the same people with expertise in khat, a widely-used stimulant in eastern Africa and the Middle East,” Dubljevic says. It simply makes sense to convene different panels to ensure that the people with the relevant expertise are at the table.

“The use of the MCDHS, regardless of whether my proposals are adopted, allows for more informed decision making by policymakers, with the potential for improving public health outcomes,” Dubljevic says. “That’s why I’d like to see the U.S. move toward incorporating the MCDHS into its drug evaluations.

“For example, it’s probable that a more complete understanding of risks could boost efforts to develop ways of limiting a drug’s potential for abuse,” Dubljevic says. “One possibility, for instance, would be to encourage the development of more delayed-release pharmaceuticals, making it more difficult for the drugs to be used recreationally.”

The paper, “Toward an improved Multi-Criteria Drug Harm Assessment process and evidence-based drug policies,” is published in the journal Frontiers in Pharmacology.

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Note to Editors: The study abstract follows.

“Toward an improved Multi-Criteria Drug Harm Assessment process and evidence-based drug policies”

Author: Veljko Dubljevic, North Carolina State University

Published: Aug. 20, Frontiers in Pharmacology

DOI: 10.3389/fphar.2018.00898

Abstract: Drug scheduling within the international system of drug control and national legislation has been recently criticized as having insufficient footing in scientific evidence. The legal harms related to non-medical uses of certain drugs (e.g., cannabis) have arguably exceeded their physiological and social harmfulness compared to legally available substances (e.g., tobacco), which prompted some states to explore alternative regulation policies, similar to the drug regime in the Netherlands. Other legally prescribed drugs (e.g., stimulants) created a surge of interest for “better than well” uses, while yet others (e.g., opioids) caused an epidemic of dramatic proportions in North America. The evidence-based multi-criteria drug harm scale (MCDHS) has been proposed as a way of grounding policy in the actual degree of harmfulness of drugs. Indeed, the scale has had great ramifications in several areas of policy, and it has been used extensively in distinct lines of interdisciplinary research. However, some aspects of MCDHS remain disputed. For example, the way the data has been generated has been criticized as suffering from “expert bias.” This article reviews strengths and weaknesses of evidence provided with the use of MCDHS. Furthermore, the author argues that the shortcomings of MCDHS can be resolved by offering methodological improvements. These include (1) dissociating the harms of use from harms of abuse, (2) adding the perspectives of people who use drugs, pharmacists, and general medical practitioners along with the expert assessments, and (3) focusing on subsets of drugs to allow for comparison without mixing different social contexts of drug use. The paper concludes with outlines of substance subset-specific extensions of the MCDHS and related policy proposals in the four areas identified as generating the most controversy: non-medical use of opioids, “study aid” uses of stimulants, shifting trends in nicotine containing products, and regulation of medical and recreational uses of cannabis.