Thursday, January 29, 2015

The 3 deadliest drugs in America are all totally legal

As the US debates drug policy reforms and marijuana legalization, there's one aspect of the war on drugs that remains perplexingly contradictory: some of the most dangerous drugs in the US are legal.

Don't believe it? The available data from the Centers for Disease Control and Prevention (CDC) shows tobacco, alcohol, and opioid-based prescription painkillers were responsible for more direct deaths than any other drug in 2011. This chart compares those drug deaths with the best available data for cocaine, heroin, and marijuana deaths:

drug deaths

Now, this chart isn't a perfect comparison across the board. One driver of tobacco and alcohol deaths is that both substances are legal and easily available. Other substances would likely be far deadlier if they were as available as tobacco and alcohol. (Heroin-linked deaths in particular have been trending up since 2010, topping 8,200 in 2013 and making heroin deadlier overall than cocaine.) And federal data excludes some deaths, particularly less direct illicit drug deaths, which is why the chart focuses on direct health complications for all drugs.

But the absolute numbers show legality doesn't indicate safety. Here's what makes tobacco, alcohol, and prescription painkillers so dangerous, and how policymakers can curb the problem.

1) Tobacco


Behold, the deadliest substance in America. (Eric Feferberg / AFP via Getty Images)

When it comes to deadliness, no single substance comes close to tobacco. To put its risk in perspective, fewer Americans die from reported drug overdoses, traffic accidents, and homicides combined than tobacco-caused health problems like lung cancer and heart disease.

Cigarette smoking is linked to one in five deaths in the US each year, according to the CDC. Nearly 42,000 of the 480,000 deaths are caused by secondhand smoke.

US tobacco use has greatly declined in the past several decades, although nearly one in five high school students and adults still smoked cigarettes in 2011. Experts attribute the decline to various factors, including education campaigns, mandatory warning labels, public and workplace smoking bans, and higher taxes on tobacco products.

2) Alcohol

alcohol fire

A person enjoys a tasty beverage by a bonfire. (Jasper Juinen / Getty Images News)

Alcohol-induced health problems, such as liver disease, led to more than 26,000 deaths in 2011. But that actually under-counts the number of deaths caused by alcohol: when including other causes of death like drunk driving and other accidents, the toll rises to 88,000 per year.

Even this higher number may understate the more general risk of alcohol. A previous report published in The Lancet took a comprehensive look at 20 of the world's most popular drugs and the risks they pose in the UK. A conference of drug experts measured all the factors involved — mortality, other physical damage, chance of developing dependence, impairment of mental function, effect on crime, and so on — and assigned each drug a score. What they concluded: alcohol is by far the most dangerous drug to society as a whole.

( Independent Scientific Committee on Drugs)

What makes alcohol so dangerous? The health effects of excessive drinking and drunk driving are two obvious problems. But there are other major issues rooted in alcohol-induced aggression and erratic behavior: injuries, economic productivity costs, family adversities, and even crime. (Alcohol is a factor in 40 percent of violent crimes, according to the National Council on Alcoholism and Drug Dependence.)

The Lancet's report comes with a couple caveats. It doesn't entirely control for the availability of these drugs, so it's possible heroin and crack cocaine in particular would be ranked higher if they were as readily available as alcohol. And the findings are based on the UK, so the specific scores would likely differ to some extent for the US.

To curb these deaths, experts often suggest tighter regulations, taxes, and more education. Previous research found that states that sold alcohol through tightly regulated, state-run establishments kept prices higher, reduced access for youth, and decreased drinking overall. And studies show that higher alcohol taxes could reduce consumption and, as a result, the problems the drug causes.

3) Prescription painkillers

prescription painkillers

These can relieve pain, but they can be dangerous — especially when paired with other drugs. (Education Images / UIG via Getty Images)

Opioid-based prescription painkillers have been linked to an increase in overdose deaths since 1999. These deaths frequently involve multiple drugs; the CDC found 31 percent of prescription painkiller-linked overdose deaths in 2011 were also related to benzodiazepines, a legal anti-anxiety drug.

Whether these prescription painkiller deaths amount to an "epidemic," as some local, state, and federal officials claim, is a matter of semantic debate in drug policy circles. Regardless of what one labels it, the general point is that prescription painkillers are linked to thousands of deaths each year. (Radley Balko, now of the Washington Post, wrote a great three-part series on the debate around this topic.)

Policymakers have responded to the deaths by putting tighter restrictions on the distribution of prescription painkillers and cracking down on "pill mills," or doctors, clinics, and pharmacies that dispense prescription painkillers unscrupulously or for non-medical reasons.

But some research found that these types of crackdowns have pushed some drug users to the more potent and dangerous heroin, indicating that there's a careful balance to strike as policymakers consider more restrictions on prescription painkillers.

There's also concerns that restricting painkillers too much makes it more difficult for people to get the medicine they genuinely need for chronic, debilitating pain. A 2011 report from the Institute of Medicine found that many Americans are under-treated for chronic pain. And multiple reports suggest doctors have avoided working in chronic pain treatment because the legal and regulatory hurdles are so big.

One way to reduce prescription painkiller deaths may be medical marijuana. One study found that states that allow pot for medicinal purposes have fewer prescription painkiller deaths than one would otherwise expect. Intuitively, this makes sense: marijuana is a potent painkiller, so it can substitute for deadlier and more addictive opioids. But experts caution this field of research needs much more study to see how much of the relationship between medical pot and prescription painkillers is causation instead of correlation.

Watch Ezra Klein's Take on the Subject

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