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. The chart above compares those drug deaths with the best available data for cocaine, heroin, and marijuana 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, 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.
Deaths also aren't the only way to compare drugs' harms. Some drugs, such as alcohol and cocaine, may induce dangerous behavior that makes someone more predisposed to violence or crime. Other drugs may trigger underlying mental health problems or psychotic episodes, like hallucinogenics. When evaluating the overall harm caused by drugs, all of these factors should be taken into account.
But the absolute numbers for deaths show legality doesn't necessarily correlate with safety. Sometimes, like in the case of alcohol and tobacco, dangerous drugs have been kept legal because they're so ingrained in the US economy and culture that it would be difficult, if not impossible, to try to ban them. Other times, as with prescription painkillers, dangerous drugs are kept legal to serve an important medical purpose. These types of considerations are just some of the many factors that play into drug policymaking, which is very often about picking the best of a lot of bad or mediocre options instead of finding the perfect solution.
With those caveats, here's what makes tobacco, alcohol, and prescription painkillers so dangerous, and how policymakers can curb the problem.

1) Tobacco

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.
The chart at the top of this article actually understates the number of tobacco deaths, since it only considers the most direct causes of deaths and excludes secondhand smoking, perinatal conditions, and residential fires.
Overall, cigarette smoking is linked to one in five deaths in the US each year, according to the CDC. Nearly 42,000 of the total 480,000 deaths from smoking 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. Continuing these efforts, public health officials hope, will continue pushing down the rate of smoking in the US.

2) Alcohol

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 analysis, led by British researcher David Nutt and 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. They concluded alcohol is by far the most dangerous drug to society as a whole.
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.)
Still, The Lancet's report has come under some major criticisms. Although drug policy experts generally agree that alcohol is dangerous — and definitely more dangerous than marijuana — they argue the report misses some of the nuance behind each drug's harms. For one, 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 — particularly for meth, which is more widely available in the states.
To show the Nutt analysis's flaws, Jon Caulkins, a drug policy expert at Carnegie Mellon University, gave the example of an alien race visiting Earth and asking which land animal is the biggest. If the question is about weight, the African elephant is the biggest land animal. But if it's about height, the giraffe is the biggest. And if the question is about length, the reticulated python is the biggest.
"You can always create some composite, but composites are fraught with problems," Caulkins said. "I think it's more misleading than useful."
The blunt measures of drug harms present similar issues. Alcohol, tobacco, and prescription painkillers are likely deadlier than other drugs because they are legal, so comparing their aggregate effects to illegal drugs is difficult. Some drugs are very harmful to individuals, but they're so rarely used that they may not be a major public health threat. A few drugs are enormously dangerous in the short-term but not the long-term (heroin), or vice versa (tobacco). And looking at deaths or other harms caused by certain drugs doesn't always account for substances, such as prescription medications, that are often mixed with others, making them more deadly or harmful than they would be alone.
Still, experts acknowledge, it's clear alcohol is dangerous and deadly. To curb the deaths and risks linked to alcohol, experts often suggest tighter regulations, taxes, and more education. A previous analysis by the RAND Corporation 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

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.

What about illicit drugs?

There's admittedly no good federal mortality data on the less direct and long-term impacts of illicit drug use. But there's reason to think the scale of overall deadliness in the chart at the top of the article wouldn't change much with additional data.
The deadliness of the harder drugs, like crack and cocaine, is severely limited in part because very few people use such substances, especially in the long-term. About 0.1 percent of the US population 12 and older reported using heroin and roughly 0.6 percent reported using cocaine in the past month, a 2013 federal survey found. (This could change if the illicit drugs were legal and more accessible.)
Still, these harder drugs are dangerous. Cocaine and crack can lead to heart attack and stroke, and they can cause violent behaviors that make someone more prone to crime. And heroin poses a massive risk of deadly overdose — a risk that only gets worse as someone uses heroin more and more, according to Keith Humphreys, drug policy expert at Stanford University.
Marijuana is more widely used, but it's never been conclusively linked to direct deaths or even other medical conditions. The research suggests using marijuana during adolescence could lead to some bad outcomes, particularly worse cognitive function. But studies have failed to conclusively link marijuana to lung disease or psychosis and schizophrenia, despite concerns from critics.
Still, marijuana carries some risks. "The main risk of cannabis is losing control of your cannabis intake," Kleiman of UCLA said. "That's going to have consequences in terms of the amount of time you spend not fully functional. When that's hours per day times years, that's bad."
Caulkins of Carnegie Mellon University put it another way: "At some level, we know that spending more than half of your waking hours intoxicated for years and years on end is not increasing the likelihood that you'll win a Pulitzer Prize or discover the cure for cancer."
But the general point of showing drugs' deadliness isn't to build a perfect rank for how dangerous each drug is. Rather, the purpose is to show that legality doesn't always correlate with safety, so people shouldn't assume that a substance is more dangerous just because it's illegal.