Harm minimisation, harm reduction, drug-related harm, drug overdose, addiction: these are the dominant narratives that are used when we talk about drugs. As doctors we diagnose those seeking treatment for many drug-use problems as having an illness.
And government policies are driven by the drug use consequences of the minority of users who develop drug dependence. Don't get us wrong: drugs – legal, illegal and prescribed – can ruin lives. Governments must provide treatment services and information. But the discourse almost always fails to explicitly and openly discuss drug-related harms in the context of the real driver behind most drug use, which is not dependence, but drug-related pleasure.
Last year's Global Drug Survey decided to explore the obvious fact that drug use, like other decisions, is one of balance. We wanted specifically to look at how the commonly used drugs in our society were rated not by scientific committees or "drug experts" but by people who actually use these drugs. Global Drug Survey did this by developing a new (and as yet unvalidated scale) called the Net Pleasure Index. It was developed after lots of feedback from our 2012 survey and discussion with many people – experts, users and expert users.
It consists of 10 items exploring the positive aspects of their drugs experience, effects and function over the last year and 10 items exploring matching negative aspects for nine drugs including tobacco and alcohol. The NPI was completed by more than 20,000 people worldwide who had used those drugs in the last year. The mean score for each drug was determined by subtracting one from another.
The results from the 7,000-strong UK sample closely match those seen in the full 22,000. It shows that when taking the good, the bad and the ugly side of drugs into consideration MDMA (ecstasy), magic mushrooms, and LSD come out top, with alcohol and especially tobacco languishing in last place.
Alcohol is rated as the most harmful drug. This may come as a surprise to many but what's striking is how closely these rankings of everyday users matched those of 29 experts who sat in a room in 2010 and generated the data for a Lancet paper calling for a review of drugs classification.
It matches the data from the World Health Organisation showing the greatest burden of drug-related disease comes from alcohol and tobacco.
The three drugs that came out top share the capacity to broaden one's inner world and scope for emotional and spiritual attachment. LSD and magic mushrooms have no recorded drug-related deaths to their name, are used sparingly by most users, and virtually no one becomes dependent.
In the case of MDMA, there are some drug deaths each year, but some of the risk and harms are associated with uncertain dosing due to variable purity and pills containing other stimulants, multiple drug use and limited implementation of common sense safer-use strategies.
Mephedrone (also known as M-cat and meow meow), once considered as a drug with a positive low-risk profile, now tops the negative rankings for after-effects and unwanted effects on mental health.
The government should not fear drug law reform. The results from this year's survey of the potential impact on drug use by current and non-users clearly shows that reducing drug penalties for small amounts of illegal drugs would, for the overwhelming majority, reduce stigma, improve discussion with families, who are the best placed to help and support individuals, and access help for their use.
Once again our work suggests that most people who use drugs do so without encountering significant harm and make sensible decisions around their use of drugs. Many more might do so if provided with information in a way that was personally meaningful and did not get in the way of them using and enjoying their drugs.
In the future, harm reduction approaches must explicitly incorporate the maintenance, and possibly even the enhancement, of pleasure, if we really want people who use drugs to see that harm-reduction advice is balanced and truly non-judgmental.
While there is much talk about harm reduction, there has been little research into what messages are most effective, how they are best communicated, and how acceptable currently recommended approaches are to users of emerging drugs.
This will be the focus of next year's Global Drug Survey. Until then if you want to see how your drug and alcohol use is affecting you and how it compares with 45,000 other people around the world, check out the drugs meter at drugsmeter.com or drinksmeter.com.