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Equasy – An Overlooked Addiction

By John Clarke
The fol­lowing post is the full text of David Nutt’s paper on “Equasy”.
Have a look at my Nutt Sacked post for details on what happened when Nutt left the ACMD.

Equasy – An overlooked addiction with implications for the current debate on drug harms

DJ Nutt Psy­cho­phar­ma­co­logy Unit, Uni­ver­sity of Bristol, Bristol, UK.
Journal of Psy­cho­phar­ma­co­logy 23(1) (2009) 3 – 5

The reg­u­la­tion of illicit drugs in the UK is via the 1971 Misuse of Drugs Act [MDAct]. That of legal drugs is via the Medi­cines Act if they have clin­ical utility or via trade reg­u­la­tions in the case of tobacco, alcohol, food sup­ple­ments and vit­amins. When a new drug comes along and con­cerns are expressed about poten­tial harm, its status is reviewed in the UK by the Advisory Council on the Misuse of Drugs [ACMD] which has a stat­utory duty to advise the UK gov­ern­ment on the harms and risks so that appro­priate policy can be gen­er­ated. Typ­ic­ally this leads to a decision to clas­sify it or not under the MDAct.

In recent years, fol­lowing a sys­tem­atic review by the ACMD, ket­amine (Nutt and Wil­liams, 2004) has been brought under the act into class C whilst khat (Wil­liams and Nutt, 2005) was con­sidered not to require reg­u­la­tion. Recently ben­zylpiperazine and related stim­u­lant drugs have been reviewed and recom­mended for a class C status in agree­ment with the EMCDDA risk ana­lysis (EMCDDA, 2007). Sim­il­arly can­nabis clas­si­fic­a­tion was reviewed in 2002 (ACMD, 2002) and down­graded to class C, a decision sub­sequently endorsed by two further reviews (Rawlins, et al., 2005, 2008). Ecstasy is cur­rently in class A, a pos­i­tion chal­lenged by the House of Commons Select Com­mittee on Science and Tech­no­logy (2006) which has lead to an ongoing review of its status.

The UK MDAct clas­si­fies drugs into three classes, A, B, C on the basis of their harm­ful­ness: Class A (the most harmful) includes cocaine, dia­morphine (heroin), 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) lys­ergic acid diethyl­amide (LSD) and methamphet­amine. Class B (an inter­me­diate cat­egory) includes amphet­amine, bar­bit­ur­ates, codeine and methyl­phen­idate. Class C (less harmful) includes ben­zo­diazepines, ana­bolic ster­oids, gamma-​​hydroxybutyrate (GHB) and can­nabis. This system of clas­si­fic­a­tion serves to determine the pen­al­ties for the pos­ses­sion and supply of con­trolled sub­stances. The current maximum pen­al­ties are as follows: Class A drugs: for pos­ses­sion – 7-​​year impris­on­ment and/​or an unlim­ited fine; for supply – life impris­on­ment and/​or fine; Class B drugs: for pos­ses­sion – 5-​​year impris­on­ment and/​or an unlim­ited fine; for supply – 14-​​year impris­on­ment and/​or fine; Class C drugs: For pos­ses­sion – 2-​​year impris­on­ment and/​or an unlim­ited fine; For supply – 14-​​year impris­on­ment and/​or fine.

How best to assess the clas­si­fic­a­tion of a drug is an issue that is and has always been prob­lem­atic. A poten­tial method for exploring harms has been developed that assesses harms across nine domains; three relate to the per­sonal harms of the drug [acute harms e.g., from over­dose, chronic harms and harms due to intra­venous use], three relate to its propensity to cause depend­ence [liking, phys­ical depend­ence and psy­cho­lo­gical depend­ence] and three cover social harms [harms from intox­ic­a­tion, (including anti-​​social beha­viour), harms from supply/​dealing, asso­ci­ated acquis­itive crime and health care costs]. Each can be scored on a 0 – 3 scale and a value for each drug derived from which a rank order of harm may be pro­duced (Nutt, et al., 2007). In this study, we also assessed alcohol, tobacco and some other misused sub­stances to provide anchor points that would allow non-​​experts and the general public to better under­stand the harms of drugs with which they might not have famili­arity. This study pro­duced a degree of public debate and con­sid­er­able media cov­erage. This taken together with the sub­sequent cov­erage of the clas­si­fic­a­tion of can­nabis (ACMD, 2008) and the ongoing review of ‘ecstasy’/ MDMA has shown that the argu­ments about rel­ative drug harms are occur­ring in an arcane manner, at times taking a quasi-​​religious char­acter remin­is­cent of medi­eval debates about angels and the heads of pins!

The reasons for this are mul­tiple and complex, but one major element is that the drug debate takes place without ref­er­ence to other causes of harm in society, which tends to give drugs a dif­ferent, more wor­rying, status. In this article, I share exper­i­ence of another harmful addic­tion I have called equasy to illus­trate an approach that might lead to a more rational and broad-​​based assess­ment of rel­ative drug harms.

The dangers of equasy were revealed to me as a result of a recent clin­ical referral of a woman in her early 30’s who had suffered per­manent brain damage as a result of equasy-​​induced brain damage. She had under­gone severe per­son­ality change that made her more irrit­able and impulsive, with anxiety and  loss of the ability to exper­i­ence pleasure. There was also a degree of hypo­front­ality and beha­vi­oural dis­in­hib­i­tion that had lead to many bad decisions in rela­tion­ships with poor choice of part­ners and an unwanted preg­nancy. She is unable to work and is unlikely ever to do so again, so the social costs of her brain damage are also very high.

So what was her addic­tion – what is equasy? It is an addic­tion that pro­duces the release of adren­aline and endorphins and which is used by many mil­lions of people in the UK including chil­dren and young people. The harmful con­sequences are well estab­lished – about 10 people a year die of it and many more suffer per­manent neur­o­lo­gical damage as had my patient. It has been estim­ated that there is a serious adverse event every 350 expos­ures and these are unpre­dict­able, though more likely in exper­i­enced users who take more risks with equasy. It is also asso­ci­ated with over 100 road traffic acci­dents per year – often with deaths. Equasy leads to gath­er­ings of users that often are asso­ci­ated with these groups enga­ging in violent conduct. Depend­ence, as defined by the need to con­tinue to use, has been accepted by the courts in divorce set­tle­ments. Based on these harms, it seems likely that the ACMD would recom­mend control under the MDAct perhaps as a class A drug given it appears more harmful than ecstasy (See Table 1).

Table 1: A com­par­ison of ecstasy and equasy using the 9-​​point scale.

Para­meter of harmEcstasyEquasy
Acute harm to person+1 per 10000 episodes++1 per 350 episodes
Chronic harm to person+?++
Intra­venous useNot applic­ableNot applic­able
Euphoric effects+++/​++
Phys­ical withdrawal-/​+-
Psy­cho­lo­gical withdrawal-/​++?
Harm to society: RTAs etc.?+ (methane emis­sions also)
Dealing harms+- (as legal)
Soci­etal costs: NHS etc.++

RTA, Road Traffic Acci­dent; NHS, National Health Service.
 – = harm; + = more harm.

Have you worked out what equasy is yet? It stands for Equine Addic­tion Syn­drome, a con­di­tion char­ac­ter­ised by gaining pleasure from horses and being pre­pared to coun­ten­ance the con­sequences espe­cially the harms from falling off/​under the horse. I suspect most people will be sur­prised that riding is such a dan­gerous activity. The data are quite start­ling – people die and are per­man­ently damaged from falling – with neck and spine frac­ture leading to per­manent spinal injury (Silver and Parry, 1991; Silver 2002). Head injury is four times more common though often less obvious and is the usual cause of death. In the USA, approx­im­ately 11,500 cases of trau­matic head injury a year are due to riding (Thomas, et al., 2006), and we can presume a pro­por­tionate number in the UK. Per­son­ality change, reduced motor func­tion and even early onset Parkinson’s disease are well recog­nised espe­cially in rural clin­ical prac­tices where horse riding is very common. In some shire counties, it has been estim­ated that riding causes more head injury than road traffic acci­dents. Viol­ence is his­tor­ic­ally intim­ately asso­ci­ated with equasy – espe­cially those who gather together in hunting groups; ini­tially, this was inter­spe­cies aggres­sion but lat­terly has become spe­cific person to person viol­ence between the pro and anti-​​hunt lobby groups.

Making riding illegal would com­pletely prevent all these harms and would be, in prac­tice, very easy to do – it is hard to use a horse in a clandes­tine manner or in the privacy of one’s own home! I suspect there would be little public or gov­ern­ment support for such an option despite the banning of inter-​​species viol­ence from equasy recently enacted in the Anti-​​Hunting bill. Indeed why should society want to control harmful sports at all? This atti­tude raises the crit­ical ques­tion of why society tol­er­ates –indeed encour­ages – certain forms of poten­tially harmful beha­viour but not others, such as drug use. There are many risky activ­ities such as base jumping, climbing, bungee jumping, hang-​​gliding, motor­cyc­ling which have harms and risks equal to or worse than many illicit drugs. Of course, some people engage in so called ‘extreme’ sports spe­cific­ally because they are dan­gerous. Horse riding is not one of these and most of those who engage in it do it for simple pleasure rather than from thrill seeking, almost cer­tainly in com­plete ignor­ance of the risks involved. Other sim­il­arly dan­gerous yet fun activ­ities are rugby, quad-​​biking and boxing. With the excep­tion of boxing, which is out­lawed in some European coun­tries, sports are not illegal despite their undoubted harms.

So why are harmful sporting activ­ities allowed, whereas rel­at­ively less harmful drugs are not? I believe this reflects a soci­etal approach which does not adequately balance the rel­ative risks of drugs against their harms. It is also a failure to under­stand the motiv­a­tions of, par­tic­u­larly younger people, who take drugs and their assess­ment of the per­ceived risks com­pared with other activ­ities. The general public, espe­cially the younger gen­er­a­tion, are dis­il­lu­sioned with the lack of bal­anced polit­ical debate about drugs. This lack of rational debate can under­mine the trust in gov­ern­ment in rela­tion to drug misuse and thereby under­mining the government’s message in public inform­a­tion cam­paigns. The media in general seem to have an interest in scare stories about illicit drugs, though there are some excep­tions (Horizon, 2008). A telling review of 10-​​year media reporting of drug deaths in Scot­land illus­trates the dis­torted media per­spective very well (Forsyth, 2001). During this decade, the like­li­hood of a news­paper reporting a death from paracetamol was in per 250 deaths, for diazepam it was 1 in 50, whereas for amphet­amine it was 1 in 3 and for ecstasy every asso­ci­ated death was reported.

Is there a lesson from these rel­ative com­par­isons of harms and risk that reg­u­latory author­ities could use to make better drug harm assess­ments and thus better laws? The example of equasy when com­pared to the use of drugs high­lights the diver­gence between the activ­ities in terms of levels of risk and social and moral accept­ab­ility. Perhaps this illus­trates the need to offer a new approach to con­sid­ering what under­lies society’s tol­er­ance of poten­tially harmful activ­ities and how this evolves over time (e.g. fox hunting, cigar­ette smoking). A debate on the wider issues of how harms are tol­er­ated by society and policy makers can only help to gen­erate a broad based and there­fore more rel­evant harm assess­ment process that could cut through the current ill-​​informed debate about the drug harms? The use of rational evid­ence for the assess­ment of the harms of drugs will be one step forward to the devel­op­ment of a cred­ible drugs strategy.

References

  • Advisory Council on the Misuse of Drugs (2002) The Clas­si­fic­a­tion of Can­nabis under the Misuse of Drugs Act 1971. London: Home Office.
  • Advisory Council on the Misuse of Drugs (ACMD) (2008) Can­nabis; clas­si­fic­a­tion and public health. London: Home Office.
  • EMCDDA (2007) https://​ednd​-cma​.emcdda​.europa​.eu/​a​s​s​e​t​s​/​u​p​l​o​ad/ Risk_Assessment_Report_BZP.pdf
  • Forsyth, AJM (2001) Dis­torted? A quant­it­ative explor­a­tion of drug fatality reports in the popular press. Int J Drug Policy 12: 435 – 453.
  • Horizon (2008) Britain’s most dan­gerous drugs. Tuesday 5th Feb­ruary 2008, 9pm, BBC Two.
  • House of Commons (2006) Select Com­mittee on Science and Tech­no­logy on Evid­ence Based Policy Making. http://www.publications. par​lia​ment​.uk/​p​a​/​c​m​2​0​0​5​0​6​/​c​m​s​e​l​e​c​t​/​c​m​s​c​t​e​c​h​/​9​0​0​/​9​0​0​-​i​.​pdf
  • Nutt, DJ (2006) A tale of two Es. J Psy­cho­phar­macol 20: 315 – 317.
  • Nutt, DJ, King, LA, Sauls­bury, W, Blakemore, C (2007) Devel­oping a rational scale for assessing the risks of drugs of poten­tial misuse. Lancet 369: 1047 – 1053.
  • Nutt, DJ, Wil­liams, T (2004) Ket­amine – an update. http://drugs. homeof​fice​.gov​.uk/​p​u​b​l​i​c​a​t​i​o​n​-​s​e​a​r​c​h​/​a​c​m​d​/​k​e​t​a​m​i​n​e​-​r​e​p​o​r​t​-​a​n​n​e​xes. pdf?view=Binary [accessed 27/​10/​2008].
  • Rawlins, M (2005) Further con­sid­er­a­tions of the clas­si­fic­a­tion of can­nabis under the Misuse of Drugs Act 1971. http://drugs.homeoffice. gov​.uk/​p​u​b​l​i​c​a​t​i​o​n​-​s​e​a​r​c​h​/​a​c​m​d​/​c​a​n​n​a​b​i​s​-​r​e​c​l​a​s​s​-​2​0​0​5​?​v​i​e​w​=​B​i​n​ary [accessed 27/​10/​08].
  • Rawlins, M (2008) Can­nabis; clas­si­fic­a­tion and public health. Home Office on line pub­lic­a­tion http://​www​.drugs​.homeof​fice​.gov​.uk/ publication-​​search/​acmd/​acmd-​​cannabis-​​report-​​2008 [accessed 27/​10/​2008].
  • Silver, JR, Parry, JM (1991) Hazards of horse-​​riding as a popular sport. Br J Sports Med 25: 105 – 110.
  • Silver, JR (2002) Spinal injuries res­ulting from horse riding acci­dents. Spinal Cord 40: 264 – 271.
  • Thomas, KE, Annest, JL, Gil­christ, J, Bixby-​​Hammett, DM (2006) Non-​​fatal horse related injuries treated in emer­gency depart­ments in the United States, 2001 – 2003. British journal of sports medi­cine 40: 619 – 626.
  • Wil­liams, T, Nutt, DJ (2005) Khat (qat): assess­ment of risk to the indi­vidual and com­munities in the UK – Home Office on-​​line pub­lic­a­tion. http://​drugs​.homeof​fice​.gov​.uk/​p​u​b​l​i​c​a​t​i​o​n​-​s​e​a​r​ch/ acmd/khat-report-2005/Khat_Report_.pdf?view=Binary [accessed 27/​10/​2008].

One Response to Equasy – An Overlooked Addiction

  1. malcolm kyle says:

    Are there evil Eques­trians hanging out in your neigh­bor­hood? Learn how to rid your­self of such a serious problem, but be pre­pared to enlist the help of others.

    1) Call the local, state and federal police.

    2) Talk to your neigh­bors and other prop­erty owners in the area about these quad­ru­ped­alist vil­lains. They may have useful inform­a­tion to relay to the police.

    3) Is this prop­erty a rental? Go to The Tax Appraisal Dis­trict to find the owner. Let them know that the “rep­robate cavalry” are on their property.

    4) Start a “Neigh­bor­hood Watch” in your area.

    * A neigh­bor­hood watch does more than just ally against horse dealers: all quality of life crimes are reduced when neigh­bors are vigilant and do not com­promise their stance. A weekly meeting with a few spliffs and pizza helps create a bond.

    * Take pic­tures of the riders (sur­repti­tiously of course), the paraphernalia left behind, like empty oat bags, provides hard evid­ence for the police to do their job.

    * Chil­dren require altern­at­ives to horses, so work with your com­munity to ensure quality options to Equasy.

    WARNING

    * Don’t threaten the eques­trians. Be wary of con­fronting them rashly; While a very small minority may be reas­on­able people, there is the dis­tinct pos­sib­ility this will be a very dan­gerous course of action.

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