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Ranking the harm of non-medically used prescription opioids in the UK

van Amsterdam, Jan; Phillips, Lawrence; Henderson, Graeme; Bell, James; Bowden-Jones, Owen; Hammersley, Richard; Ramsey, John; Taylor, Polly; Dale-Perera, Annette; Melichar, Jan; van den Brink, Wim; Nutt, David


Jan van Amsterdam

Lawrence Phillips

Graeme Henderson

James Bell

Owen Bowden-Jones

Richard Hammersley

John Ramsey

Polly Taylor

Annette Dale-Perera

Jan Melichar

Wim van den Brink

David Nutt


A panel of nine experts applied multi-criteria decision analysis (MCDA) to determine the relative overall harm to users and harms to others of street heroin (injected and smoked) and eleven non-medically used prescription opioids. The experts assessed harm scores for each of the 13 opioids on each of 20 harm criteria, weighted the criteria and explored the resulting weighted harm scores for each opioid. Both forms of heroin scored very high: overall harm score of 99 for injected heroin and 72 for smoked heroin on a scale of 0–100. The main feature that distinguishes both forms of street heroin use is that their harm to others is more than five times that of the other eleven opioids. The overall harm score of fentanyl (including injection of fentanyl extracted from patches) and diamorphine (medically prescribed form of heroin) was 54 and 51, respectively, whereas that of orally used opioids ranged from 32 (pethidine) to 11 (codeine-containing pharmaceuticals). Injected street heroin, fentanyl and diamorphine emerged as most harmful to users, with the latter two very low in harm to others. Pethidine, methadone, morphine and oxycodone are also low in harm to others, while moderate in harm to users. We conclude that the overall harms of non-medically used prescription opioids are less than half that of injected street heroin. These data may give a basis for precautionary regulatory measures that should be considered if the rising trend in non-medical use of prescription opioids were to become evident in the UK.


van Amsterdam, J., Phillips, L., Henderson, G., Bell, J., Bowden-Jones, O., Hammersley, R., …Nutt, D. (2015). Ranking the harm of non-medically used prescription opioids in the UK. Regulatory toxicology and pharmacology : RTP, 73(3), 999-1004.

Acceptance Date Sep 10, 2015
Publication Date Dec 1, 2015
Deposit Date Oct 23, 2015
Publicly Available Date Nov 23, 2017
Journal Regulatory toxicology and pharmacology
Print ISSN 0273-2300
Electronic ISSN 1096-0295
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 73
Issue 3
Pages 999-1004
Keywords Opioids, MCDA, Risk assessment, Ranking, Prescription drugs, Harm, Street heroin
Public URL
Publisher URL
Additional Information Authors' accepted manuscript of an article published in: Regulatory toxicology and pharmacology, 2015, v.73, issue 3.


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