Unveiling Canada's First Comprehensive Drug Harm Ranking

The landscape of substance use in Canada has been reshaped by a groundbreaking research publication from the Centre for Addiction and Mental Health (CAMH), affiliated with the University of Toronto. Published on January 27, 2026, in the Journal of Psychopharmacology, the study titled "Drug harms in Canada: A multi-criteria decision analysis" marks the nation's inaugural use of multi-criteria decision analysis (MCDA) to rank the harms of 16 psychoactive drugs. Led by Jean-François Crépault and involving a panel of 20 multidisciplinary experts from across six provinces, this academic endeavor draws on expertise from leading Canadian universities and health institutions.

At the forefront of this revelation is alcohol, identified unequivocally as Canada's most harmful drug. Contrary to widespread focus on the opioid crisis, the study assigns alcohol a cumulative harm score of 79 out of 100, dwarfing other substances. This finding challenges public perceptions and underscores the pervasive impact of a legally available and culturally entrenched substance. The research, conducted during a two-day decision conference in Toronto in November 2024, integrates prevalence data from national surveys with expert judgments on harm severity.

Researchers from institutions like Dalhousie University, University of Calgary, and the University of Toronto contributed pivotal insights, highlighting the role of higher education in advancing public health knowledge. This publication not only informs policy but also positions Canadian academics at the vanguard of global drug harm assessments, mirroring methodologies used in the UK, EU, Australia, and New Zealand.

The Rigorous Methodology Behind the Rankings

Multi-criteria decision analysis (MCDA) is a structured analytical framework that evaluates complex decisions by breaking them into measurable criteria. In this study, experts assessed 16 drugs across 16 harm domains, categorized into physical, mental, and social harms to both users and others. Scores ranged from 0 (no harm) to 100 (maximum harm), with weights assigned via swing weighting to reflect relative importance. Population-level prevalence was factored in using data from Canadian Alcohol and Drugs Survey (CADS) and other sources, shifting focus from individual dose harm to aggregate societal impact.

The process unfolded step-by-step: First, panelists reviewed evidence on each criterion, such as drug-specific mortality or economic costs. Then, they scored drugs relative to the worst performer (set at 100). Software like HiView3 aggregated weighted scores. Harms to users included dependence, withdrawal, and loss of relationships; harms to others encompassed injury, crime, and environmental damage. This Canadian-adapted model added withdrawal as a criterion and tailored weights to local contexts, like high opioid toxicity deaths from fentanyl contamination.

Expert panelists hailed from diverse fields—epidemiology, psychiatry, criminology, and Indigenous health—ensuring balanced perspectives. Affiliations with universities such as the University of British Columbia and McGill University enriched the analysis with cutting-edge research.

Alcohol Dominates: The Complete Harm Score Rankings

The results paint a stark picture. Alcohol leads with 79 points, followed by tobacco at 45, non-prescription opioids at 33, cocaine and methamphetamine tied at 19, and cannabis at 15. Lower-ranked substances include prescription opioids, benzodiazepines, and others not detailed here but assessed similarly.

This table, derived directly from the study, illustrates alcohol's dominance across nine of 16 categories, including physical health damage and social adversity.

Decoding Alcohol's Supremacy Over Opioids

While non-prescription opioids claim third place due to acute risks like overdose (responsible for over 80% of drug toxicity deaths), alcohol's lead stems from its ubiquity. Approximately 78% of Canadians aged 15+ report past-year use, per 2019 CCSA data, enabling massive aggregate harm. Alcohol causes over 200 health conditions, from cancers to accidents, with annual economic costs nearing $20 billion—far exceeding opioids' $7.1 billion in 2020.

Opioids, though devastating, affect fewer users; their harms are amplified by unregulated markets leading to contaminated supplies. Alcohol, conversely, benefits from lax regulations, fostering increased availability via privatized sales in some provinces. This disparity prompts calls for parity in policy responses.

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Detailed Harms: From Personal Toll to Societal Burden

Alcohol excels in user harms like chronic diseases (liver cirrhosis, breast cancer) and acute incidents (falls, violence). Long-term mental impairments, such as depression, compound physical tolls. Socially, it drives family breakdowns and productivity losses.

Harms to others are profound: intimate partner violence, child neglect, and road fatalities (421 impaired driving deaths in 2014). Economic fallout includes $5.9 billion in lost productivity alone. In contrast, opioids' interpersonal harms are lower, focused on overdose witnessing.

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• Physical harm to users: High due to direct organ damage.
• Mental functioning: Intoxication impairs judgment acutely.
• Harm to others: Tops in injury and economic cost.

Higher Education Under the Spotlight: Alcohol's Campus Impact

Canadian postsecondary institutions face acute challenges. The 2024-2025 Canadian Postsecondary Education Alcohol and Drug Use Survey (CPADUS) reveals 75% of students used alcohol in the past year, with 25% suffering harms from others' drinking—emotional distress topping the list. Earlier data shows 55% experience annual negative consequences like academic interference.

Universities like Humber Polytechnic report heavy episodic drinking among 45% of past-month users. Research from first-year residences highlights cultures exacerbating harms, yet policies lag—Atlantic campuses implement only 47% of evidence-based measures.

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Voices from the Experts: Panel Insights

JF Crépault emphasized, “Alcohol clearly stands out... highlighting a major gap between harms and regulation.” Dr. Jürgen Rehm noted, “Alcohol combines serious harms with widespread use.” Panelists like Sherry H. Stewart (Dalhousie) and David Hodgins (U Calgary) stress holistic views beyond physical effects.

Indigenous health expert Robert Henry advocates culturally sensitive approaches, reflecting diverse stakeholder views.

The Steep Economic and Health Costs

Alcohol-attributable hospitalizations hit 87,911 in 2014, costing billions. Updated estimates peg total societal costs at $19.7 billion annually, surpassing all illicit drugs combined. Productivity losses alone rival healthcare expenditures.

In universities, harms translate to missed classes and mental health strains, burdening counseling services.

Policy Shifts and Recommendations

The study urges evidence-based interventions: pricing hikes, availability curbs, and warning labels—proven globally. Align alcohol policies with proven opioid strategies like harm reduction.

Universities should bolster policies; only half potential realized currently. Future research from Canadian academics will refine these.

Aligning with Canada's Alcohol Guidance

The 2023 CCSA update to Low-Risk Alcohol Drinking Guidelines declares no safe level; low-risk is under 2 standard drinks weekly. This complements the CAMH findings, promoting "less is better."

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• 0 drinks/week: Lowest risk.
• 1-2/week: Low risk for consequences.
• 3-6/week: Moderate risk for cancers.

Charting a Healthier Future: Actionable Steps

As this landmark study from CAMH and university experts reverberates, Canadians—from students to policymakers—must prioritize alcohol harms. Campuses can lead with education and support.

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Visit the full study for deeper analysis: Journal of Psychopharmacology.