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and compression-only CPR done spontaneously by bystanders who might or might not be trained. When the 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 aect 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 adult primary 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 dierence between asphyxial and primary cardiac arrest. Therefore, ideally, lay people should continue to be trained 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 Soar
Department 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

JPN is co-chair of the International Liaison Committee on Resuscitation and editor-in-chief of Resuscitation. JS is chairman of the UK Resuscitation Council and an editor of Resuscitation. 1 Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010; 3: 6381. Rea TD, Eisenberg MS, Culley LL, Becker L. Dispatcher-assisted cardiopulmonary resuscitation and survival in cardiac arrest. Circulation 2001; 104: 251316. Hp M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet 2010; published online Oct 15. DOI:10.1016/S0140-6736(10)61454-7 Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med 2000; 342: 154653. Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compresssions alone or with rescue breathing. N Engl J Med 2010; 363: 42333. 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. Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L, for the European Resuscitation Council. European Resuscitation Council guidelines for resuscitation 2005. Section 2: adult basic life support and use of automated external debrillators. Resuscitation 2005; 67 (suppl 1): S723. Bobrow BJ, Zuercher M, Ewy GA, et al. Gasping during cardiac arrest in humans is frequent and associated with improved survival. Circulation 2008; 118: 255054. ONeill JF, Deakin CD. Evaluation of telephone CPR advice for adult cardiac arrest patients. Resuscitation 2007; 74: 6367. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA 2010; 304: 144754. Kitamura T, Iwami T, Kawamura T, Nagao K, Tanaka H, Hiraide A, for the Implementation Working Group for All-Japan Utstein Registry of the Fire and Disaster Management Agency. Bystander-initiated rescue breathing for outof-hospital cardiac arrests of noncardiac origin. Circulation 2010; 122: 29399. Kitamura T, Iwami T, Kawamura T, et al, for the Implementation Working Group for All-Japan Utstein Registry of the Fire and Disaster Management Agency. Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. Lancet 2010; 375: 134754. Roppolo LP, Pepe PE, Cimon N, et al, for the Council of Standards Pre-Arrival Instruction Committee; of the National Academies of Emergency Dispatch (writing group). Modied cardiopulmonary resuscitation (CPR) instruction protocols for emergency medical dispatchers: rationale and recommendations. Resuscitation 2005; 65: 20310.

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Ranking of drugs: a more balanced risk-assessment

Published Online November 1, 2010 DOI:10.1016/S01406736(10)62000-4 See Articles page 1558

Adolescents have a natural drive to investigate the unexpected, and experiencing the eects 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. Dierent regulatory approaches have therefore been used to restrict the adverse eects 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 ecacy 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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parties that follow from alcohol, tobacco, and drugs use provide a useful aid for politicians and policy makers for how to classify (illicit) drugs, with the ultimate goal to establish an eective and proportionate drug classication. 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 dierent 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 classication in the UK. In their interpretation, the investigators rightly conclude that their ndings correlate poorly with present UK drug classication. This conclusion is not surprising, because the UK drug-classication 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 classication is a matter of debate, but certainly deserves serious consideration. An approach based on possible harm reduction in drug control seems to be more promising to reduce the burden than does a classication based on prohibition. A drug-ranking study in the Netherlands4 also assessed the relative adverse eects of recreational drugs both at the individual and the societal level. As such, the nancial 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 ndings than is the previous study by Nutt and colleagues,3 conrming 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 eects. For example, magic mushrooms have a low incidence of adverse eects, 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
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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 denitive, 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 classication, it is intriguing to note that the two legal drugs assessed alcohol 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 Brink
Laboratory 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 conicts of interest. 1 2 Van den Brink W. Forum: decriminalization of cannabis. Curr Opin Psychiatry 2008; 21: 12226. Nutt DJ, King LA, Phillips LD, on behalf of the Independent Scientic Committee 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. Nutt D, King LA, Sualbury W, Blakemore C. Development of a rational scale to assess the harm of drugs of potential misuse. Lancet 2007; 369: 104753. van Amsterdam JGC, Opperhuizen A, Koeter M, van den Brink W. Ranking the harm of alcohol, tobacco and illicit drugs for the individual and the population. Eur Addiction Res 2010; 16: 20207. Hearn WL, Rose S, Wagner J, Ciarleglio A, Mash DC. Cocaethylene is more potent than cocaine in mediating lethality. Pharmacol Biochem Behav 1991; 39: 53133. Ramaekers JG, Robbe HWJ, OHanlon JF. Marijuana, alcohol and actual driving performance. Human Psychopharmacol Clin Exp 2000; 15: 55158.

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