MR. KOJO NNAMDIWhich of these substances is more dangerous, crack cocaine, heroin, alcohol? If you're considering the havoc they can wreak on a single user's physical body or their performance at work, you'd probably say cocaine or heroin. But if you consider what is worse for society writ large, alcohol is far more destructive or so says a new study in the British Medical Journal, The Lancet. Researchers took 20 drugs and compared them across 16 different measures, what kind of long term physical and mental damage they left in users, how strongly they were linked to crime, how much they end up costing the economy and local communities.

MR. KOJO NNAMDIThe study questions some of the basic assumptions we make about substance abuse and its effect on society. Joining us to talk about that study is David Nutt. He's a professor of neuropsychopharmacology at the Imperial College of London where he's director of the psychopharmacology unit at the University of Bristol. He's also lead author of "Drug Harms in the UK: A Multicriteria Decision Analysis," that was published in the Medical Journal, The Lancet. He joins us from BBC studios in London. David Nutt, thank you for joining us.

MR. DAVID NUTTYeah, it's a pleasure.

NNAMDIHow can you say whether one substance is worse than another? To compare these drugs, you use something you called multicriteria drug analysis. What is multi -- or multicriteria drug analysis?

NUTTWell, as you said in your introduction, we look to cross a scale of 16 different harms. So if you look at every single harm a drug can cause, you get 16. Nine of them relate the harms the drug does to the person who takes it and seven relate to the harms drugs do to society. And then, what we did was we scaled every drug, every -- all the 20 drugs against each other on each of those harms and we came up with an overall score. And in terms of harm to the individual, crack cocaine, heroin, crystal meth came above alcohol. Alcohol came fourth.

NUTTBut when you look at society, the harms to others, alcohol came out on top. And that's largely because of the damage through the health costs of alcohol, the road traffic accidents, the violence, the domestic violence as well as the street violence. And the fact is, you know, so many people use it. So many people end up suffering as a consequence.

NNAMDIOne thing that separates alcohol from all of those other substances is that it's available legally in almost every restaurant and bar, both in the U.S. and in the UK. It's consumed by a relatively large percentage of the population and it's regulated and taxed.

NUTTYeah, that's right. And there's a paradox there, isn't there? So we regulate it, we tax it, but still we have vast amounts of use. And we have more of a problem in the UK than you have in the U.S. because you actually have somewhat more rational laws about alcohol in the U.S. For instance, you know, you have a driving law, a drinking law, which says that you can't drink until you're 21, whereas in Britain, it's 18. And we know that your law has saved tens of thousands of lives of young people who haven't died on the roads in drunk related, drink related road traffic accidents.

NUTTBut there's still unquestionably in both countries, alcohol is too cheap because there is still too much damage caused by it. And we're not regulating it appropriately. And that is really one of the key messages from our paper, that we should be developing new ways of regulating alcohol use to minimize the cost on society. 'Cause I've estimated in the UK, every taxpayer pays about nearly $2,000 a year extra tax just to cover the damage that alcohol causes in terms of health, in terms of traffic accidents, in terms of the extra policing needed to deal with disorder produced by alcohol.

NNAMDIAnd it raises another issue, one I would like our audience to weigh in on by calling 800-433-8850. That other issue, should we classify drugs based on the harm they do to the user or the harm they do to others, to society? 800-433-8850 or you can go to our website, kojoshow.org. You can send us a tweet at kojoshow or send us an e-mail to kojo@wamu.org. We're talking with David Nutt. He is the author of "Drug Harms in the UK: A Multicriteria Decision Analysis," that was published in The Lancet Medical Journal.

NNAMDI800-433-8850. When it comes to government regulation and taxation and prohibition, David Nutt, many of our policies are grounded and received wisdom about why we use certain substances and how they affect our bodies. This received wisdom is apparently at odds with your latest findings about the damage to society.

NUTTYeah, absolutely right. And I don't think anyone who works in the medical profession who knows about the harms of alcohol would be surprised. We, in Britain, we have predicted literally within 10 years liver disease, mostly alcohol produced, will kill more people than heart disease. We're on an epidemic of liver related death. That is growing year on year. And we know this. Even our parliamentarians know it, but no one has the courage to which you stand up and say we must do something about it.

NUTTAnd that's really why I was quite keen to put the paper out there in the public. I mean, when we discovered just how badly alcohol did in terms of harms to others, we thought it was really critical that this gets into the public domain. And we have a proper debate because the public need to realize what it's costing them to have cheap alcohol.

NNAMDIIn the UK, you classify drugs as class A, class B, class C. Here in the U.S., the Controlled Substances Act creates schedules of drugs. Schedule one drugs include heroin, schedule two includes oxycontin, schedule four includes things like valium. In the UK, class A, heroin and crack cocaine and class C is where you find cannabis or marijuana. These different tiers make sense, but they can prompt major battles about where each drug belongs. How in your view should that process work?

NUTTWell, the classification system, if drugs are properly classified, it's a very powerful tool because it directs education about drug harms. It directs police time and effort and it also directs sentencing. But for a number of years, me and many other people have been very unhappy with our classification system. Just like yours, there are some anomalies. For instance, our -- this current research and previous research we did, published three years ago, suggested that drugs which we put in the top schedule, like ecstasy, should never be classified there.

NUTTIt's wrong to consider ecstasy or LCD or magic mushrooms as harmful as crack cocaine and heroin. And yet we have tried all our efforts to the politicians to change their views have fallen on deaf ears. And that means there are people who are being unjustly penalized with very severe prison sentences for schedule one drugs.

NNAMDII would suggest that your efforts are not only falling on deaf ears, in your case, they seem to be falling on hostile ears. Until last year, you were a senior advisor to the labor government in the U.K. on drugs. But when the British government increased its penalties for possession of marijuana, you criticized the move and you were actually fired from that position. Tell us about that.

NUTTWell, that's right. I mean, we have this absurd situation in Britain in the last four or five years of the last labor government where we were telling them that the real target for health interventions or legal interventions should be alcohol as -- and they had done some good work on tobacco. So they've actually made real progress on tobacco. And when we said, look the next one, the really big one is alcohol, they said, oh we're not interested in that. We're going to really come down hard cannabis users, you know. On almost every single metric, cannabis is less harmful than alcohol.

NUTTAnd I just thought that that was both dishonest, intellectually dishonest, it was also wrong in terms of political direction and certainly in terms of economic interest and it was unjust. Criminalizing people for using a drug which is less harmful than alcohol seems, to me, unjust. And I cannot understand how any kind of mature society can sanction it.

NNAMDIIt does point to a challenge facing some scientists and doctors who work for governments in a policy capacity. What happens when your research takes you to a point where you are at odds with your employer? In this case, the government.

NUTTYes, it's an interesting challenge, isn't it?

NNAMDIIt's -- yes.

NUTTIn fact it's a challenge which you've seen, you know. You had your deputy drug Czar McLellan resign recently because he found it too difficult to work in government and with the knowledge base that he had, which was essentially saying that the government policy was actually not in line, not in phase with his evidence. So it's very difficult, but I think we have to keep speaking out because if we don't, then there will be greater harms from drugs and greater injustice. So, yeah, it's tough, but, you know, as they say, someone's got to do it and I -- hopefully, the general public is sympathetic to what we're trying to do, which is minimize harm and improve justice.

NNAMDILet me start going to the telephones with Joe in Ashburn, Va. Joe, you're on the air. Go ahead, please.

JOEHi, Kojo, thanks a lot. Hey, I have a couple questions about the validity of the study. First, were all the criteria weighted or were they weighted equally? And if they were weighted, did you do a sensitivity analysis to see how the results would change based on different weighting scenes? And...

NUTTI shall answer that now?

NNAMDIYes, please. One at a time, Joe.

NUTTLet me answer the first question because it's...

NNAMDIYes.

NUTT...hard to remember the second one. So absolutely. The real benefit, there were two major advances in this current study. One was getting all the harms de-convoluted so I don't think anyone could say we haven't covered every base in terms of the harm, the 16 harms. That was the first thing. The second thing is we did exactly as you suggested, we did weightings. Now, those weightings were done by an expert panel, a panel of people who treat drug addicts and research drug addiction. But the power of this multicriteria decision analysis is that anyone can do the weightings.

NUTTAnd what we're trying to do is we're trying to roll out now the process into other groups that have opinions. So I'm hoping to get politicians to do the weightings. I'm hoping to get members of the general public to do the weightings. I'm hoping to get Americans to do the weightings. One of the things I'd like to do is come and do the same study with a selection of U.S. experts next year to see whether they come up with the same weightings. The process does enable different weightings to be applied and then we can see if different results come out.

NNAMDIJoe, the second part of your question?

JOEYeah, that sounds great. The second part is with the cannabis, you know, the -- and I agree whole heartedly that cannabis is less of a problem than alcohol. However, it seems like there's no way, like with alcohol, you can determine someone's impaired right now. In the case of cannabis, you can tell if they've used it recently, but you can't tell if they're impaired right now. And that seems to be one, at least for me, that's one of the road blocks to legalizing. I can't tell if someone's driving impaired or not when it comes to cannabis.

NNAMDIWell, that...

JOEIs that a true statement?

NNAMDI...that was not the focus of the study, but David Nutt may have an opinion on that.

NUTTSure. And I understand where you're coming from. And, in fact, there are two very different problems which come from your observations. And let's focus on cannabis in the first instance. So the first problem is, of course, that people can have cannabis detected weeks after they've used it. And therefore, they can be accused of being intoxicated, even though they're not.

NUTTBecause as we know, the effective intoxication disappears within about 12 to 24 hours, but the detection of the drug can persist for weeks. So there's a scope for injustice there. But the other side of your question was, you know, is if you are driving and you're driving or doing something else while you're impaired with cannabis, people wouldn't know. Now, I would say the analogy with alcohol is not quite fair because we set an arbitrary threshold for the level of alcohol in the body.

NUTTIn your country for driving I think it's the same as ours. I think it's 18 milligrams percent. Now, in other countries it's set lower, in other countries it's set higher. So there is no absolute truth in the decisions that governments make about what's safe and what's not, and of course, the risk of having a traffic accident goes up. It doesn't even go up linearly, it goes up exponentially as alcohol levels rise.

NUTTSo even alcohol isn't a perfect solution to the problem. It might be possible to develop a test which could set you a threshold of cannabis. It might be possible. But I personally would prefer going back one step, and saying what's important is not what you've taken, it's how you're driving. And we could develop objective measures of competence wish then would get -- would actually be applicable across any drug. We wouldn't have to worry about the drug. We'd just say are you competent, are you not.

NNAMDIJoe, thank you very much for your call. We move onto Claire in Annapolis, Md. Claire, you're on the air. Go ahead, please.

CLAIREHi, Kojo. Thanks for allowing me to make a comment. I had a 17-year-old son who died of a binge drinking accident in 2007, in which he mixed energy drinks and hard alcohol. Southern Comfort is what I was told. And he passed out and was found, and had been with peers without adult supervision, outside of my home. And I guess I have a couple thoughts. One is I like the idea of a classification system.

CLAIREHe had .32 percentage of alcohol in his blood at the time it was tested by the coroner. And I guess I think about the education that needs to go on in terms of alcohol poisoning, and the effects that alcohol can have on our health. So just thought I would throw that out there.

NNAMDIAnd we are very sorry for your loss, Claire, but glad you called. I'd like to hear David Nutt's response.

NUTTClaire, I am utterly with you on this. There are so many parents that have lost children through binge drinking, and yet there is no voice for them. It's completely paradoxical that the only voice we hear in Britain are the voice of parents who believe, probably wrongly, that cannabis has caused their children to have schizophrenia. But so many more have suffered like you have, a young person dying of alcohol poisoning.

NUTTAnd just to take the example of your son, the blood alcohol level was 320. That's only four times the legal drinking limit. That is why alcohol is a dangerous drug. Because the ratio between an intoxicating dose and a lethal dose is so low. We should make much more of this. There should be a major, major effort by parents like you who've lost children to alcohol, to protest to the government to sue the industry and to raise public awareness.

NUTTAnd I want to say one other thing. And this is a really scary development that is not properly understood, and not much talked about. But this mixing of stimulants like caffeine, these caffeinated high-energy drinks, with alcohol gives people a false sense of their ability to tolerate alcohol. What it does is, is stops from falling asleep when the blood alcohol levels get to 100, 150, 200. So they keep on drinking. And they get the lethal levels like your son did.

NUTTWe have seen active marketing of these strong caffeinated drinks to young people, specifically to allow them to drink more alcohol and cause more alcohol damage to themselves. And that's another great concern of mine, and I really wish it was in the public domain more.

NNAMDIClaire, thank you for your call. Here in the U.S. we've had a debate about so-called four loco, malt beverages mixed with caffeine. It has since been banned. We're going to take a short break. When we come back we'll talk with an addiction expert here on this side of the Atlantic on this issue. 800-433-8850 is the number to call. Or if the lines are busy, go to our website, kojoshow.org. Make a comment or ask a question there. I'm Kojo Nnamdi.

NNAMDIWe're discussing the social effects of alcohol addiction with David Nutt. He's a professor of neuropsychopharmacology at the Imperial College of London, and the author of the article, "Drug Harms in the UK: A Multicriteria Decision Analysis." That study was published in the medical journal, Lancet. He joins us from BBC studios in London.

NNAMDIJoining us from here in the United States by phone is Charles O'Brien. He's a professor of psychiatry and director of the Center for Studies of Addiction at the University of Pennsylvania in Philadelphia. He chairs the substance-related disorders workgroup for the American Psychiatric Association. Dr. O'Brien, thank you for joining us.

MR. CHARLES O'BRIENWell, thank you. I'm to be here.

NNAMDIIn some ways, this is an outgrowth of a different article that Dr. Nutt wrote in the Lancet three years ago. Dr. O'Brien, can you tell us a little bit about your reaction to Dr. Nutt's work?

O'BRIENWell, actually, he and I are good friends, and I think there's very little difference between us. I think there is a good deal of difference between our two countries in terms of the public health approaches to many of these drugs, but scientists really don't disagree. You know, we go by the facts, and he know the facts as well as I do.

NNAMDIYou are chair of the American Psychiatric Association Substance-Related Disorders workgroup, a group of researchers working on revisions to the diagnostic statistical manual of mental disorders. How does this kind of research about the relative destructiveness of different drugs fit into that?

O'BRIENWell, our work is to provide the clinician with diagnostic criteria to help them make a diagnosis and to provide the best treatment. And actually, even bigger than our committee is the new health care reform that President Obama and Congress has recently gotten through. Because that is going to be a wonderful improvement in the approach to drugs in the United States. Until now, we don't start treating them until they get to be really severe, and anyone can make the diagnosis.

O'BRIENBut since we have to do something to reduce the increasing cost of medical care, one way to do that is to treat the drug problems earlier, and that will end up causing less cost for liver transplants and heart disease and cancer. So all doctors are going be required to identify drug problems very early, and get people into treatment early so we will actually save money in the healthcare system by treating more people with drug disorders.

NNAMDICharles O'Brien, David Nutt talked a little bit earlier about the difference in the U.S. approach to regulating drugs and that in the U.K. I'd like your take on that difference.

O'BRIENWell, in general, you know, if I could just start from sort of an abstract position. In the U.S. we tend to see drug problems more as a police law and order issue. And so we spend over two-thirds of our funds on the so-called war on drugs on trying to keep drugs out of the country. Coast Guard cutters, border patrols, jet planes, and all that, and spraying poppy fields.

O'BRIENAnd that's been pretty ineffective. Right now in my city of Philadelphia, heroin is pure and cheaper than ever before, and many of the kids on opiates are getting them through prescription sources anyway. So that never works, but we spend relatively little on prevention and treatment. And we have a history of actually using the law. For example, in the early part of the 20th century, it became illegal for doctors to treat people with addiction in their offices.

O'BRIENAnd there were so many opiate addicts at the time that some doctors wanted to continue treating them. And so many doctors actually went to prison for violating the law for treating people. And until the 1960's, the only places that opiates could be treated was in two prison hospitals in Lexington and Fort Worth. So we have always tended to use the law, and beginning in the 1970's we started becoming a little more medically oriented.

O'BRIENBut still the use of methadone for example is illegal to treat addiction, except in certain centers. And another major change has been the availability of Buprenorphine which doctors can finally use in their offices to treat opiate addiction. But we are much more law and order oriented than most of my European friends.

NNAMDIExcept in one regard, David Nutt, what I heard you saying earlier seems to be that in terms of regulating, we get alcohol right, and what I hear Charles O'Brien saying is that you get drugs right.

NUTTWell, yeah. I mean, you're more rational about alcohol. I mean, you still have major problems, but you've done some sensible things, like increasing the drinking age from 18 to 21. That was a mature thing. You also have many counties in the U.S. where you don't allow supermarkets to sell alcohol, which reduces the availability. We had this wave of alcohol-related deaths, because people can go into supermarkets at 3:00 in the morning and buy several, in your terms, quarts of cheap alcohol and drink it until they die.

NUTTIt's harder to do that in the U.S. So you have a slightly better regulated system.

O'BRIENWell, actually, in the U.S. it depends on the state. For example, I know some western states where you can buy alcohol from your car in a drive-up window and get drunk without even getting out of your car.

NUTTOkay, yeah.

NNAMDIYeah. I depends on the state. Um, we got this e-mail from Chandry in Washington, D.C. "Don't drugs such as heroin and cocaine have huge costs to society including all of the military expenses for counter-narcotics efforts, billion in aid to Columbia, etc.?" First you, David Nutt. Is that something that you took into consideration when looking at the social costs?

NUTTIndeed. In fact, we took -- we took two -- we took into consideration two separate criteria. One was the international damage that the drugs trade causes, which of course is absolutely enormous in countries like Columbia and Mexico. And then of course, also we looked in the economic damage and economic costs to our societies in terms of prohibition. So absolutely. You know, that was a major consideration for two of the 16 parameters.

NNAMDIHere is Will in Louis -- go ahead, Charles O'Brien.

O'BRIENWell, it's wasted money though. I mean, you know, so much of it is useless because if you just go to buy heroin on the street of Philadelphia now, it is so much cheaper and more potent than it used to be even 20 years ago. So there -- it's true. Your e-mailer is right. We're spending a lot of money on all those things, but we still have all of the problems, and we should be doing more in terms of prevention and treatment.

NNAMDIOnto...

NUTTI totally agree.

NNAMDIOnto Will in Lewisburg, W. Va. Will, you're on the air. Go ahead, please.

WILLHi, Kojo. Thanks for taking my call. A comment and a question. First off, on the comment, I agree with Mr. Nutt's assessment that, you know, a lot of our drug laws seem completely arbitrary. For example, the distinction between crack cocaine, regular cocaine, and how penalties appear more severe for crack. And also, I'm a college-aged kid. I've been around a lot of people doing a variety of substances, and I have to say, you know, I've seen people do a lot less harm to themselves and others when they're smoking weed than when they get drunk.

WILLI have a -- I guess a two-part question. The first part is...

NNAMDIRaise it one part at a time because we're running out of time.

WILLOkay. The first part is what he proposes to do with the information of this study for governments, you know, whether he proposes like blanket decriminalization, or legalization or just a change in the penalties. And then also this is kind of related, real quick, does the study take into account projections of what, you know, the damage would be society if, for example crack was legalized.

WILLYou know it seems to me that if you have a population, you know, an entire population where...

NUTTYeah. I fully understand your question. Fully understand your question.

NNAMDIHere is David Nutt.

NUTTRight. So yeah. A lot of -- I want to make it absolutely clear, I'm not a legalizer. I think where we have legalized drugs and actively marketed them like alcohol and tobacco, we run into greater problems. What I think, very briefly, is that this process, this -- this set of 16 criteria should be applied by all lawmakers in the world in the sense that they tell you how to evaluate drug harms.

NUTTI'd like them taken up by the WHO in the United Nations as the bedrock criteria against which we decide drug harms. And in term s of policy, I think it's morally difficult to defend a position where you -- you criminalize and prison people for using drugs which are less harmful than alcohol. So I think some kind of regulated access such as the Dutch coffee shop model is the appropriate way forward for drugs which are less harmful than alcohol.

NUTTFor drugs like crack, and crystal meth, and heroin, I can't see how we could have regulated access. I just think we need to do what Chuck is saying. We need to try to stop use from the user's perspective by treatment rather than stop importation which is expensive and not work.

NNAMDICharles O'Brien, you get the last comment.

O'BRIENWell, I think that we both agree that we ought to be doing more to educate the public, and there's so much more. I mean, and I think that we're lucky in our country that we're about to have healthcare reform that is going to be aimed at doing just that. Because treating drug addiction in the United States is a major tenant of healthcare reform. So I think in the next couple of years we're all going to see an improvement in the right approach.

NNAMDIAnd I'm afraid that's about all the time we have. Charles O'Brien, thank you so much for joining us.

O'BRIENYou're welcome.

NNAMDICharles O'Brien is professor in the department of psychiatry at the University of Pennsylvania School of Medicine. And David Nutt, thank you for joining us.

NUTTIt's been a real pleasure, thank you very much.

NNAMDIDavid Nutt is professor of neuropsychopharmacology at the Imperial College of London and author of "Drugs Harms in the UK: A Multicriteria Decision Analysis" that was published in the Lancet medical journal. He joined us from BBC studios in London. Charles O'Brien is also director of the Center for Studies of Addiction at the University of Pennsylvania in Philadelphia.

NNAMDI"The Kojo Nnamdi Show" is produced by Brendan Sweeney, Tara Boyle, Michael Martinez and Ingalisa Schrobsdorff, With help from Katherine Goldgeier and Elizabeth Weinstein. Diane Vogel is the managing producer. The engineer today, Timmy Olmstead. Dorie Anisman has been here. Thank you all for listening. I'm Kojo Nnamdi.