An MCDA framework for evaluating and appraising government policy for psychoactive drugs Professor Larry Phillips London School of Economics and Facilitations Limited OR58 Annual Conference 7 September 2016

Context Collaboration: DrugScience + Frisch Centre Purpose DrugScience (Professor David Nutt is founder and Chair) Ragnar Frisch Centre for Economic Research (Ole Rogeberg is the lead researcher) Funded by the Norwegian Research Council. Purpose Develop an analytic framework for describing, measuring, assessing and discussing drug policy Decision conferences 10-11 September 2015 and 20-21 January 2016 18 participants, various backgrounds Phillips & Nutt facilitating Three models to test framework: alcohol, cannabis and heroin

Policy (Strategy) Table Production Sale/distribution Purchase Purchase volume (for legal users) Possession Use Illegal (strong sanctions) None - illegal Illegal (weak sanctions - de jure or de facto decriminalized) Per person quotas Legal with restrictions for individuals (e.g, legal to brew wine, not spirits; grow cannabis, not more than 5 plants, grow "magic mush-rooms" in limited volume) Only gifting between individuals (no money involved) Only adult licensed users (e.g., tested for knowledge of harms and principles of safe use) Per purchase quotas Limited quantity per person (e.g., for personal use) Only in specific, certified venues (e.g. pubs or on-site consumption with monitoring such as user rooms or use retreats) Legal with restrictions for groups (e.g., cannabis clubs where users combine to finance growing for members) State-run retail stores (e.g., state alcohol monopolies) Only adults (age restrictions) Self set quotas changeable with lag No restrictions Only in private homes State controlled State-licensed retail stores or pharmacies Only in specific licensed venues or private homes No restrictions for companies Only mail-order Anywhere except certain public spaces (e.g, indoor smoking bans) No restrictions for companies or individuals No restrictions - any retail store 34,300 combinations

Policy (Strategy) Table Production Sale/distribution Purchase Purchase volume (for legal users) Possession Use Illegal (strong sanctions) None - illegal Illegal (weak sanctions - de jure or de facto decriminalized) Per person quotas Legal with restrictions for individuals (e.g, legal to brew wine, not spirits; grow cannabis, not more than 5 plants, grow "magic mush-rooms" in limited volume) Only gifting between individuals (no money involved) Only adult licensed users (e.g., tested for knowledge of harms and principles of safe use) Per purchase quotas Limited quantity per person (e.g., for personal use) Only in specific, certified venues (e.g. pubs or on-site consumption with monitoring such as user rooms or use retreats) Legal with restrictions for groups (e.g., cannabis clubs where users combine to finance growing for members) State-run retail stores (e.g., state alcohol monopolies) Only adults (age restrictions) Self set quotas changeable with lag No restrictions Only in private homes State controlled State-licensed retail stores or pharmacies Only in specific licensed venues or private homes No restrictions for companies Only mail-order Anywhere except certain public spaces (e.g, indoor smoking bans) No restrictions for companies or individuals No restrictions - any retail store

Purchase volume (for legal users) Policy options Absolute Prohibition State Control Decriminalisation Free Market Production Sale/distribution Purchase Purchase volume (for legal users) Possession Use Illegal (strong sanctions) None - illegal Illegal (weak sanctions - de jure or de facto decriminalized) Per person quotas State controlled State-licensed retail stores or pharmacies Only adults (age restrictions) Per purchase quotas Limited quantity per person (e.g., for personal use) Only in specific licensed venues or private homes No restrictions for companies or individuals No restrictions - any retail store No restrictions

Drug Harm Policy Value Tree 7 impacts Health Social Political Public Crime Economic Costs 27 evaluation criteria (with clear definitions)

Cluster Criterion Definition Health Harm to user Prevents medical harms to a user resulting from consumption of intended substance; includes blood-borne viruses (BBV) Harm to others Prevents health harms (including BBVs) to third parties due to either indirect exposure (e.g., second hand smoking) and behavioural responses to consumption (e.g., injury due to alcohol induced violence) More harmful substances Decreases consumption of more harmful substances or increases consumption of less harmful substances (e.g., cannabis prohibition leading to synthetic cannabinoids) Encourages treatment Encourages treatment of substance-use problems Product quality Assures the quality of products due to mislabelled or counterfeit/adulterated product, unknown dose/purity Social Education Improves education about drugs Medical use Policy does not impede medical use Research Policy does not impede research Human rights Policy does not interfere with human rights as distinct from the individual’s right to use. Individual liberty Policy does not interfere with individual liberty (individual’s right to use) Community cohesion Policy does not undermine social cohesion in communities Family cohesion Policy does not undermine family cohesion Political International development & security Policy does not undermine international development and security Industry influence on governments Impedes drug industry influence on governments (less lobbying is preferable) Public Promotes well-being Promotes social and personal well-being Children and young Protects children and young people Protects vulnerable Protects vulnerable groups other than children and young people Religious/cultural value Respects religious or cultural values Crime Criminalises users Does not criminalise users Reduces acquisitive crime Reduces acquisitive crime to finance use Reduces violent crime Reduces violent crime due to illegal markets Prevents corporate crime Prevents corporate crime, e.g. money-laundering, tax evasion Prevents criminal industry Extent to which the policy discourages illegal market activity Economic Generates state revenue Reduces economic costs Reduces public financial costs not directly related to the enforcement policy (e.g., spillover effects on health policy budgets) Cost Introduction Financial costs of introducing the policy Maintenance Financial costs of enforcing the policy

Scoring the options Direct scoring of harm 100 Least harm 80 60   Least harm 80 60 Relative Strength of Harm 40 20 Most harm

There are no data about the future. But, the four policies are all hypothetical states about the future. There are no data about the future. So, how reliable (repeatable) and valid (represent actual harm) are direct preference judgements?

UK drug harms: 2010 ISCD results 2010

Europe drug harms: 2013 Europe results 2013

UK 2010 vs. Europe 2013 Europe UK Direct preference judgements are reliable and valid in a decision conference if: Criteria are defined clearly Group members represent differing perspectives Peer review occurs face-to-face Group is properly facilitated r = 0.993

Swing-weighting the criteria “How big is the difference between most and least preferred options and how much do you care about it?” 1. Weight swings below each node, e.g., Health Impacts.…….Economic Impacts.…………………..Costs 2. Weight most important swings across the nodes. Purpose of weights: To ensure comparability of units of preference across the model. (They do not represent absolute importance.)

MCDA results Alcohol Cannabis For both drugs, a legal but strictly regulated market is judged to yield the best outcomes overall.

Decriminalisationbetter Alcohol State control vs. Decriminalisation State control better Decriminalisationbetter

Decriminalisationbetter Cannabis State control vs. Decriminalisation State control better Decriminalisationbetter

Sensitivity analyses at each node cannabis State Control remains most preferred option over a wide range of weights. Also for alcohol.

Current state Alcohol results confirm current public health and medical opinion. Not so for cannabis. For both substances, a legal but strictly regulated market is judged to yield the best outcomes overall. Was there a ‘reformist bias’ in the group? Need further research by other teams. We now have the beginnings of a coherent analytic framework for describing, measuring, assessing and discussing drug policy

A guide to further reading Multi-criteria analysis: a manual, 2000 (Dodgson, Spackman, Pearman & Phillips) Chapter 6 is an MCDA tutorial. Cambridge University Press, 1993 The book that introduced MCDA in 1976 (Wiley). UIT Cambridge Ltd, 2012 Explains the harms of misusing psychoactive legal & illegal drugs.