Mental Health Matters: Is alcohol the most dangerous drug in America? (opinion) |

Mental Health Matters: Is alcohol the most dangerous drug in America? (opinion)

Andrew Whyman
File photo |

Editor’s note

This fall, both California and Nevada citizens will vote on ballot initiatives to legalize the sale of cannabis, i.e., marijuana. This is the second in a 3-part series of opinion pieces from Dr. Whyman in relation to marijuana and other drugs.

Click here to read Part One. Look to in the coming weeks for Part Three.

In my column two weeks ago, I described the history of how and why America criminalized certain drugs during the last 100 plus years.

One reader found the column “disgraceful.” Great! At least one person read it. Maybe I can add to the confusion with this column.

Today I propose to discuss “drug harms,” or the harm of one drug compared to another. I consider legal drugs, like caffeine, tobacco and alcohol; and illegal drugs, like heroin, cocaine, methamphetamine and marijuana.

This analysis turns out to be more complex that it might seem at first. For example, is alcohol the most dangerous drug? If you use vehicular deaths associated with a substance as a measuring stick, the legal drug alcohol is the most dangerous drug, followed by legally prescribed opiates.

But this would be misleading, because many more people drink alcohol and take legal opiates for pain control than, for example, use the dangerous drugs heroin and cocaine.

So, if many more people use one substance that causes impairment in judgment, coordination and alertness than another, you can be confident that it will be associated with more vehicular deaths than a substance that is used much less frequently, even if the latter one is actually more dangerous for the individual using it.

There is no one universally accepted measure of drug harms, and likely never will be, because the effect of a drug is influenced by the environment in which it is taken.

For example, provide cocaine in a laboratory setting and there is no evidence of the agitated and aggressive behavior associated with its use on the street. Or provide a sedative drug, explaining to the subject that it is a “stimulant,” and the person becomes more animated and alert.

Still, there is scientific consensus that certain drugs are more harmful than others, a consensus growing out of hundreds of research studies.

One methodology compares the acute lethality, i.e. the likelihood of dying, of commonly abused drugs. Using this metric, heroin and alcohol are the most dangerous, followed by cocaine, with minor tranquilizers farther down the list, and marijuana at the bottom.

Using dependence potential as the metric, heroin and crack cocaine rank “very high,” smoked opium ranks “high,” smoked cocaine and tobacco are “moderate to high,” valium, alcohol and methamphetamine rank “moderate,” and caffeine and marijuana are “moderate to low.”

Assessing the absolute number of drug-related deaths, opioids, cocaine and alcohol are at the top; minor tranquilizers, methadone, antidepressants and heroin are in the middle; and stimulants and marijuana are at the bottom.

In a recent study (Journal of Psychopharmacology, 2015, pp 655-660), 40 drug experts scored 20 drugs on 16 harm criteria. Alcohol, heroin and crack cocaine were by far the most harmful drugs, and marijuana and ecstasy were much less harmful.

Looking at legal and illegal drug use through a prevalence lens won’t tell you about the danger of a substance for the individual user, but it does provide a window into understanding how to address the problem.

In 2014, there were 27 million Americans aged 12 or older who used illicit drugs (ID) in the past 30 days, a whopping 10.2% of the population, higher than each of the preceding 12 years (Substance Abuse Sourcebook, 2016).

A remarkable 22.2 million were marijuana users and 4.3 million were non medical prescription drug users. The number of heroin users, while much smaller, also rose during this period.

Place these numbers in perspective by comparing them with alcohol and tobacco use: In 2014, there were 66.9 million tobacco users and 139.7 million alcohol users including 60.9 million binge drinkers.

A remarkable 22.8% of the underage population were alcohol users, and 13.8% of them were binge drinkers.

Another important comparison: 17 million Americans had an alcohol use disorder, while 7 million had an illicit drug use disorder. Put another way, the population of people with serious alcohol-related problems is more than twice that of all illicit drugs combined.

All of this research reveals inescapable conclusions: Legal alcohol use, both in terms of prevalence in the population and danger to the individual, is the most dangerous substance. The illegal drugs heroin, cocaine and methamphetamine rank next in order along the dangerousness continuum. Marijuana, while much more prevalent than other illegal drugs, is also much less dangerous.

An effectively functioning democracy requires both an informed citizenry and a politics based on fact. The marijuana initiatives on both the California and Nevada ballots this fall should challenge both groups.

Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at

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