Equasy - An overlooked addiction with implications for the current debate on drug harms
by Prof. David J. Nutt
Psychopharmacology Unit, University of Bristol, Bristol, UK.
Journal of Psychopharmacology 2009; 23; 3
All the versions of this article:
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).
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
4 Equasy – a harmful addiction with implications for the current debate on drug harms 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
Advisory, Council on the Misuse of Drugs (2002) The Classification of
Cannabis under the Misuse of Drugs Act 1971. London: Home
Advisory Council on the Misuse of Drugs (ACMD) (2008) Cannabis;
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Forsyth, AJM (2001) Distorted? A quantitative exploration of drug
fatality reports in the popular press. Int J Drug Policy
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.
Nutt, DJ (2006) A tale of two Es. J Psychopharmacol
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rational scale for assessing the risks of drugs of potential misuse.
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Silver, JR, Parry, JM (1991) Hazards of horse-riding as a popular
sport. Br J Sports Med
Silver, JR (2002) Spinal injuries resulting from horse riding accidents.
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
Williams, T, Nutt, DJ (2005) – Khat (qat): assessment of risk to the individual and communities in the UK, Home Office on-line publication. [accessed 27/10/2008].