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JPN is co-chair of the International Liaison Committee on Resuscitation and

editor-in-chief ofResuscitation. JS is chairman of the UK Resuscitation Counciland an editor ofResuscitation.

1 Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival fromout-of-hospital cardiac arrest: a systematic review and meta-analysis.Circ Cardiovasc Qual Outcomes 2010; 3: 6381.

2 Rea TD, Eisenberg MS, Culley LL, Becker L. Dispatcher-assistedcardiopulmonary resuscitation and survival in cardiac arrest.Circulation 2001; 104: 251316.

3 Hpfl M, Selig HF, Nagele P. Chest-compression-only versus standardcardiopulmonary resuscitation: a meta-analysis. Lancet 2010; publishedonline Oct 15. DOI:10.1016/S0140-6736(10)61454-7

4 Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitationby chest compression alone or with mouth-to-mouth ventilation.N Engl J Med 2000; 342: 154653.

5 Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compresssions aloneor with rescue breathing. N Engl J Med 2010; 363: 42333.

6 Svensson L, Bohm K, Castrn M, et al. Compression-only CPR or standard

CPR in out-of-hospital cardiac arrest. N Engl J Med 2010; 363: 43442.7 Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L, for

the European Resuscitation Council. European Resuscitation Councilguidelines for resuscitation 2005. Section 2: adult basic life supportand use of automated external defibrillators. Resuscitation2005;67 (suppl 1): S723.

8 Bobrow BJ, Zuercher M, Ewy GA, et al. Gasping during cardiac arrest inhumans is frequent and associated with improved survival.Circulation 2008; 118: 255054.

9 ONeill JF, Deakin CD. Evaluation of telephone CPR advice for adult cardiacarrest patients. Resuscitation 2007; 74: 6367.

10 Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression only CPR by layrescuers and survival from out-of-hospital cardiac arrest.JAMA 2010;304: 144754.

11 Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Hiraide A, for theImplementation Working Group for All-Japan Utstein Registry of the Fire andDisaster Management Agency. Bystander-initiated rescue breathing for out-of-hospital cardiac arrests of noncardiac origin. Circulation 2010; 122:

29399.12 Kitamura T, Iwami T, Kawamura T, et al, for the Implementation Working

Group for All-Japan Utstein Registry of the Fire and Disaster ManagementAgency. Conventional and chest-compression-only cardiopulmonaryresuscitation by bystanders for children who have out-of-hospital cardiacarrests: a prospective, nationwide, population-based cohort study.Lancet 2010; 375: 134754.

13 Roppolo LP, Pepe PE, Cimon N, et al, for the Council of StandardsPre-Arrival Instruction Committee; of the National Academies ofEmergency Dispatch (writing group). Modified cardiopulmonaryresuscitation (CPR) instruction protocols for emergency medicaldispatchers: rationale and recommendations. Resuscitation 2005;65: 20310.

and compression-only CPR done spontaneously by

bystanders who might or might not be trained. Whenthe cause of cardiac arrest is asphyxial (including most

paediatric cases),11,12 and when emergency medical

response times are longer than 46 min, standard CPR

might produce better outcomes.

How should the results of these meta-analyses affect

practice? If the information from a caller suggests sudden

adult cardiac arrest, the dispatcher should provide

instructions assertively on compression-only CPR. Thus

the kiss of life should be replaced by Keep It Simple,

Stupid, which is broadly consistent with the practice of

many emergency medical dispatchers in the UK. For adultprimary cardiac arrest, dispatchers instruct the bystander

to give 600 compressions (about 6 min) followed by two

rescue breaths and then a compression:ventilation ratio of

100:2 until emergency medical personnel arrive (Barron T,

International Academies of Emergency Dispatch, Bristol,

UK, personal communication).13 The general role of

bystander compression-only CPR is less clear. A bystander

who starts CPR will not know how long the emergency

medical services will take to arrive, and will not understand

the difference between asphyxial and primary cardiac

arrest. Therefore, ideally, lay people should continue to betrained in standard CPR. But any CPR is better than no CPR.

Compression-only CPR has an important role in increasing

the rate of bystander CPR by those who are untrained,10

who have only a minimum time for training, or who are

unwilling or unable to provide rescue breathing.

*Jerry P Nolan, Jasmeet SoarDepartment of Anaesthesia, Royal United Hospital NHS Trust,

Bath BA1 3NG, UK (JPN); and Department of Anaesthesia,

Southmead Hospital, North Bristol NHS Trust, Bristol, UK (JS)

jerry.nolan@nhs.net

Ranking of drugs: a more balanced risk-assessment

Published Online

November 1, 2010

DOI:10.1016/S0140-

6736(10)62000-4

SeeArticlespage 1558

Adolescents have a natural drive to investigate the

unexpected, and experiencing the effects of recreational

drugs, either licit or illicit, is part of that drive. However,

the use of such drugs might not only result in physical

and mental harm for the user, but can also present great

burdens to society, such as aggression, car accidents,

criminality, poverty, job absence, and health-care costs.

Different regulatory approaches have therefore been used

to restrict the adverse effects of licit and illicit drug use,

varying from punitive prohibition, to partial liberalisation,

to full legislation of the drug market. We have argued that

criminalisation of drug use has low effi cacy in reducing

the prevalence of drug misuse, and even seems to

promote petty and organised crime.1 Therefore a broader

and more sophisticated approach should be considered.

The results of David Nutt and colleagues study2 in

The Lancet on the ranking of drugs with respect to the

harms to individual users and the societal harms to third

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Comment

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parties that follow from alcohol, tobacco, and drugs use

provide a useful aid for politicians and policy makersfor how to classify (illicit) drugs, with the ultimate

goal to establish an effective and proportionate drug

classification. This study is an extension of a previous

ranking study by Nutt and colleagues3 but is more

balanced and accurate because of the introduction of

weighting factors for the different criteria and the use

of more detailed criteria to assess the overall harm of

tobacco, alcohol, and drugs. As such, the new data

provide a valuable contribution for the re-evaluation

of current drug classification in the UK. In their

interpretation, the investigators rightly conclude thattheir findings correlate poorly with present UK drug

classification. This conclusion is not surprising, because

the UK drug-classification system is subject to national

and international drug policies, which are also based

on considerations other than the harm of a drug, as

presented by Nutt and colleagues. To what extent the

harm of drugseither at the individual or societal level,

as assessed here in a rational mannershould prevail

in the drug classification is a matter of debate, but

certainly deserves serious consideration. An approach

based on possible harm reduction in drug controlseems to be more promising to reduce the burden than

does a classification based on prohibition.

A drug-ranking study in the Netherlands4 also assessed

the relative adverse effects of recreational drugs both at

the individual and the societal level. As such, the financial

costs and burden for society related to recreational drug

use could be properly introduced as determinants in the

overall assessment. With the same approach, Nutt and

colleagues results are more comparable and compatible

with the Dutch findings than is the previous study

by Nutt and colleagues,3 confirming its international

generalisibility.

A major point not addressed in the study, because

it was outside the investigators scope, is polydrug

use, which is highly prevalent in recreational drug

users. Notably, the combined use of alcohol with other

drugs often leads in a synergistic way to very serious

adverse effects. For example, magic mushrooms have

a low incidence of adverse effects, but if consumed

in combination with alcohol they have led to some

fatal accidents (JvA, unpublished observation). Other

examples are the concomitant use of alcohol and cocaine

leading to the highly toxic compound cocaethylene,5 and

the extreme impairment of driving after the combined

use of cannabis and alcohol.6

Nutt and colleagues ranking of the licit and illicit

drugs is certainly not definitive, because the pattern

of recreational drug use is dynamic: the popularity and

availability of the drugs, and the pattern of polydrug use,

might change within a decade. The ranking of the drugs

should therefore be repeated at least every 510 years.

Finally, for the discussion about drug classification, it is

intriguing to note that the two legal drugs assessedalcohol and tobaccoscore in the upper segment of the

ranking scale, indicating that legal drugs cause at least as

much harm as do illegal substances.

*Jan van Amsterdam, Wim van den BrinkLaboratory for Health Protection Research, National Institute for

Public Health and the Environment, 3720 BA Bilthoven,

Netherlands (JvA); Academic Medical Center, University of

Amsterdam, Department of Psychiatry, Amsterdam, Netherlands

(WvdB); and Amsterdam Institute for Addiction Research,

Academic Medical Center, Amsterdam, Netherlands (WvdB)

Jan.van.Amsterdam@rivm.nl

We declare that we have no conflicts of interest.

1 Van den Brink W. Forum: decriminalization of cannabis. Curr Opin Psychiatry2008; 21: 12226.

2 Nutt DJ, King LA, Phillips LD, on behalf of the Independent ScientificCommittee on Drugs. Drug harms in the UK: a multicriteria decision analysis.Lancet 2010; published online Nov 1. DOI:10.1016/S0140-6736(10)61462-6.

3 Nutt D, King LA, Sualbury W, Blakemore C. Development of a rational scaleto assess the harm of drugs of potential misuse. Lancet 2007; 369: 104753.

4 van Amsterdam JGC, Opperhuizen A, Koeter M, van den Brink W. Rankingthe harm of alcohol, tobacco and illicit drugs for the individual and thepopulation. Eur Addiction Res 2010; 16: 20207.

5 Hearn WL, Rose S, Wagner J, Ciarleglio A, Mash DC. Cocaethylene is morepotent than cocaine in mediating lethality. Pharmacol Biochem Behav 1991;39: 53133.

6 Ramaekers JG, Robbe HWJ, OHanlon JF. Marijuana, alcohol and actualdriving performance. Human Psychopharmacol Clin Exp 2000; 15: 55158.

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