—:
`
`ELLEN S. ROME MD, MPH
`Head, Sedion offidolesoent Medicine,
`Oeveland Oinic
`
`It’s a rave new world: Rave culture
`and illicit drug use in the young
`
`I ABSTRACT
`
`lllidt orug use by young people hasdnanged in the last
`decade with the increasing useof “ designer” or“ dub”
`drugs sudn as etstasy. Keeping abreast of airrent trends in
`illicit drug use prepares the primary we dinidan to
`reoognize the diniml effects of drug use, to manage drug
`emergencies and to dated addictive behavior. Todays
`widely used drugs, their street naneq their effeds, and how
`to manage overdoses are reviewed.
`
`I KEY POINTS
`
`Fbpular " designer” drugs include ecstasy, gamma-
`hydroxybutyrate (GI-B), Rnhypnol, ketamine herbal ecstasy
`(ma huang, ephedra), and methamphetamine.
`
`Designer drugs are easily obta'naole and affordable at
`raves—all-night danoe parties with marathon dancing to
`electronic“ted1no” dance music
`
`Other substam associated with rave culture include
`
`“smart drinks’ sold for rehydration; these may oontain ma
`huang, caffeine, guarana (a caffeine-like stimulant), and
`ginseng.
`
`V\hen questioning teens and young adults about drug use,
`a nonoonfrontaional approach helps The dinidan needs
`to establish Confidentiality and to da‘inethe limits of that
`confidentiality
`
`' PATIENT INFORMATION
`
`Date rape drugs: V\hat parents should know, page561
`
`N EW AND POTENTIALLY dangerous illicit
`drugs are popular among young people
`today. Relatively little is known about the
`short-term and long-term adverse a‘fects of
`these drugs or how to test for them.
`A major trend since the ealy 19905 has
`been the use of ”dougter” or “club” drugssucln
`as “’ecstasf at raves—al-nigit dance parties
`with marathon danci ngto electronic“techno”
`music. Use of the dedgner drugs gamma
`hydroxybutyrate (GH B), Rohypnol, and keta-
`mine, also called “date rape” drugs is wide
`spread enough to have prompted Congeesto
`adopt the Drug-Induced Rape Prevention and
`Punishment Act of 1996, which incrmd
`Federai pendtiesfor use of any control led sub-
`stanceto aid in sexua assault (see “ Date rape
`drugs: What parents should know,” page
`551).
`Drug abuse leads to short—term and long-
`term health problems Keeping abreast of
`trends in illicit drug use enhances the dini—
`cian’sabi lityto recognizeand manage overdos
`asand to pick up duasof addiction in young
`patients Thisartide briefly reviewsthe scope
`ofillicit drugusein young peopleandthemost
`popula' dadgier drugs
`
`I THE SCDPE OF DRUG ABU$
`IN THEYOJNG
`
`Illicit drug use continues to be prevaent
`among young people. Some of the drugs used
`a'e familiar (aoohol, marijuana) and some are
`newer and perhaos unfamiliar to many of us1
`The percentage of 8th gaders reporting
`illicit drug use doubled from 11.3% in 1991 to
`21.4% in 1995.2 Then, a‘ter 1 or 2 years of
`declinein the late 1990s the use of marijuana
`amphetamines tranquilizers heroin, and aco-
`
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`ILLICIT DRUG USE
`
`ROME
`
`The rave scene: A closer look
`
`E AVESARE PARTiEswith loud, electronic“tech-
`
`laser light shows and al-
`no-rock” music,
`nigit dmdng They are held in dandedine loca
`tions including warehouses nightclubs and fa'm
`fields Theyfirst becamepopular in Great Britain in
`the late 1980s
`
`Alcohol isnot sold at many raves but des'gwer
`and other drugs are obtainable a1d affordable. In
`addition, “ power drinkS’ are usudly sold: these are
`fruit juice mixed with amino acid powders and B
`vitamins to replenish fluids Ios during arewous
`marathon dancing.
`
`SDHEADING'I'I-IEVIORD
`
`Two to three days before a rave, information about
`the location is di$eminated via the Internet (eg,
`Iinksaccessiblefrom www.da10esafe.org), fliers or
`word of mouth. Raves a‘e sometimes advertised
`
`under alluring names arch as“ Rave N ew World” or
`“Save the Rave Fored.”7 Raves attract mainly peo-
`ple 16 to 21 years old, but younger teens and some
`adults also frequent these parties A s'nge rave in
`Ohio attracted young people from a five-state aea
`Some rave fmsgo from city to city in search of the
`next best rave.
`
`OTHERTYPESOF RAVES
`
`“Bush parties’ are outdoor parties often with a
`sports focus acohol use at these events tends to
`exceed drug use.
`
`“Circuit parties’ are weekend-long parties or
`raves with a homosexual orientation,
`involving
`5,000 to 20,000 people Patygoers travel
`from
`event to event, with some of these paties being
`substantialy linked economically to fundra'sing or
`cultural events
`
`In Montrea, thiscircuit has been edimated to
`bethe$cond Ia'gest money maker for thei r tourisn
`industry.
`
`ATI'EIVIPTS'I'O MAKE DRUG UEAT RAVES SAFER
`
`Drug safety check stations. Because the
`des'gier drugs sold at raves are not aways pure,
`many raves now feature stations where ugs can
`have the purity of their drugs checked, without the
`risk of being arested for pose- on. Thisisa‘i effort
`to increase the safety of illicit drug use by letting
`users know exactly what they a'e taking. Many
`local policedmatme’rtsarrest onlythoseindividu—
`ascaugit selling drugs
`Safe spaces. In Montreal, physicians often go
`to ravesto create ”safe spaces" for medical triage
`and urgent referral to Ioca emergency rooms This
`practice isone of damage control rather than pri-
`mary prevention and has been controversial
`among adolescent medicine profo- onals On one
`hand,
`this practice has prevented deaths from
`overdose and has provided a source of education;
`but on the other hand,
`it does little to decrease
`actua drug use.
`
`hol among 8th, 10th, and 12th gadersstopped
`declining and leveled off from 1998 to 1999,
`according to the National Institute on Drug
`A buse’s 1999 M onitoring the Future study.3
`
`Alcohol
`
`Alcohol isthe mos widely used drug among
`young people, with four out of every five Su-
`de1ts having consumed alcohol by the end of
`higq school, and 52% by the 8th gade.3
`Almost two thirds of 12th gaders and one
`fourth of 8th gade's reported having been
`drunk at
`least once3 Binge drinking rates
`have leveled off in the pas few yeas just as
`des' 91a drugs started gaining in populaity
`Alcohol-drug combinations. A popular
`trend is to combine alcohol with over-the-
`
`counter drugs One e><anp|eisa“robos10t”—
`1 to 2 ouncesof Robitussin DM chugged with
`a 12-ounoe beer. This allegedly produces a
`“bud equivalent to a six—pack of beer, with-
`out a1y hmgove.
`
`Marijuana
`Ma‘ijuena isthe second most widely used drug
`among young people: 17% of 8th graders 32%
`of 10th graders and 38% of 12th graders
`reported having used it at least once, aid 1.4%
`of 8th gade's 3.8% of 10th gaders and 8.0%
`of 12th gaders reported daily use.3
`
`Inhalants
`
`For the past 5 years the use of inhalants by
`students surveyed in the Monitoring the
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`

`Future Study has Seadily declined, with 10%
`of 8th gaders 7% of 10th gaders and 6% of
`12th gadersreporting useat least once during
`1999. The data for the year 2000 show
`inha ant use continues to be more prevaent
`in younger teens4
`Inhalants are readily accessible. A wide
`range of common household products are
`used,
`including gue, solvents butane, gaso-
`line, and aerosols
`
`Anabolic steroids
`
`Among young people, use of anabolicsteroids
`ismore common in boystha’i in g'rls Steroid
`use increased in 1999, with 2.5% of 8th
`graders and 2.8% of 10th graders using
`steroids3 These rates almost doubled com-
`
`pared with 1998 rates of 1.6% and 1.9%,
`respectively, and fewer 12th gaders consid-
`ered steroids as risky asthey did the previous
`year. The 2000 Monitoring the Future study4
`showed that between 1999 and 2000 the use
`
`of awabolic steroids increased among 10th
`gaders
`
`Designer drugs
`A number of drugs are used by teens and
`young adults who frequent raves, bars and
`nightclubs where they are relatively easy to
`obtain and affordable. Popular dugier drugs
`currently incl ude:
`-
`Ecstasy, the common name for 34 meth-
`ernedioxymethanphetamine (M DMA),
`also called “A dam” and “XTC”
`
`-
`
`fl unitrazepan
`. The date rage drugs GH B,
`(known mainly by its brand na'ne,
`Rohypnol), and ketamine
`Herbal ecstasy, another nane for ma
`huang or ephedra
`- Methamphetamine.
`The makeup of these dugier drugs as
`well as their des'red effects their short-term
`and long-term adverse effects, and how to
`manage overdose are discussed later in this
`aticle.
`
`Ecstasy. In a random survey of illicit drug
`use in undergraduates attending Tulane
`University in 1990, use of eciasy was report-
`ed by 24% of those surveyed.5 In 1996, 5% of
`US 16-year-olds
`reported ecstasy use.6
`Accordi ng to the 1999 Monitori ngthe Future
`Study,3 4.4% of 10th gadersmd 5.6% of 12th
`
`gaders reported using ecdasy in the past year.
`The 2000 Monitoring the Future Study
`showed that the use of ecSasy by al three
`goupsincreased.4
`GH B isadate rape drug either intention-
`ally used or surreptitiously administered to
`incapacitate a victim, preventing her or him
`from res'fiing sexual assault. As with other
`date rape drugs its use isnot confined to date
`rape situations
`No data on the prevalence of its use are
`available as of this writing. Nevertheless
`the problem of GH B, Rohypnol, and keta-
`mine use received sufficient national atten-
`
`tion to prompt Congress to pass a law
`increasing penaltiesfor using drugsin sexual
`assault.
`
`is an anti-azure drug avail-
`Rohypnol
`able in Europe but not in the United States
`Rohypnol use showed a smdl decline in
`1999, with 0.5% of 8th graders a1d 1.0% of
`10th and 12th graders reporting use.3
`Rohypnol may be lethal when combined
`with alooho|.3,7
`
`Ketanineisarapid—acting genera anes
`thetic u$d asan alternative to cocaine and
`
`usually snorted. No data on the prevalence
`of ketamine use are available asof thiswrit-
`
`ing.
`
`l ECSTASY
`
`Ecstas/(MDMA, XTC, X, E, Adan) isasyn-
`thetic, ps/choactive, hallucinogenic drug,
`first synthesized in Germany by Merck in
`1914 to facilitate communication during psi-
`chotheraoy8 It is an amphetamine analogue
`and a selective serotonergic neurotoxin.
`Experimentation in humans has been traced
`back only to the early 197059 Its use was
`criminaiized in theUnited Statesin 1985,9 by
`which time it hadjumped from the ps/chia-
`trist’scouch to the dancefloor.
`
`Much of what issold asecstasy isnot pure
`MDMA, but may bea'iy combination of 3,4—
`methylenedioxyamphetamine (M DA,
`the
`love pill, the love drug, or speed for lovers),
`N-ethyI-methylendioxyanphetamine (M DE
`Eve),
`lysergic acid diethylanide (LSD),
`amphetamine, caffeine, heroin, or
`lactose.
`MDE produces effects similar to those of
`MDMA but turnsthe subject inwards
`
`GHB, Rohypnol,
`and ketamine
`
`are the date
`
`rape drugs
`
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`CLEVELAND CLINIC JOURNAL OF MEDICINE
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`JUNE 2001
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`ILLICIT DRUG USE
`
`ROME
`
`Commonly abused drugs
`associated with serious heat injury
`or rhabdomyolysis
`
`Amphetarri nos
`Cocaine
`
`MDVIA (ecstasy)
`Methamphetamine (crystal meth, ice)
`Phenwdidine (PCB
`
`
`A 100-mg
`tablet of
`
`ecstasty costs
`
`$20
`
`How ecstasy is taken
`MDMA comes in the form of a white, crys
`taline powder which can be buffered and
`prwd into pills10 The usual dose taken by
`young people is] to 2 mg/kg body wei git (125
`to 180 mg). A 100—mg tablet usually costs
`around $20. It may be ingested orally placed
`under the tongue, added to juice or a carbon-
`ated beverage, or snorted intranasaly.
`“ Candyflipping" is the intentional com-
`bination of ecsaey with LSD.
`“Stacking’ means ta<ing three or more
`tabletsat once, or mixing MDMA with LSD,
`alcohol, or maijuanain order to modulatethe
`hign. Those who stack may take different
`drugsat different timesthrouglout an evening
`to modify their high: eg, they start with ecsta-
`sy, add antphetantine or coca'newhilecoming
`down, and add cannabis alcohol, GHB, or
`ketantine as the evening continues Stacking
`increasesthe risk of overdose, asthe stimulant
`effects of MDMA may mad< the sedative
`effects of alcohol or opiates Moreover, alco-
`hol use can induce diures's further aug‘nent-
`ing the risk of dehydration from the marathon
`dancingtypica at raves
`
`How ecstasy works
`M DMA hasa half-lifeof6 hours and theti me
`to onset of action vaiesgeetly from person to
`person.
`It works by releasing serotonin and
`dopaniine into the brain. This surge of sero-
`tonin creates the feeling of love or eciasr
`extending to all people with whom the uy
`comes into contact. The release of dopantine
`keepsthe user from feeling any pain. Thus a
`user may dance for hours on a broken ankle
`without reaiz'ng it.
`
`The release of neurotransmitters also
`
`decreases body temperature perception, and
`usersof M DMA can overheat without feeling
`any discomfort (TABLE 1).
`
`The ecstasy ‘rush’
`Ingestion of ecstas/ isfollowed by an almost
`infiantaneous “ rush,” occurring in aoproxi-
`mately 30 to 45 secondsif taken on an e‘npty
`stomach. This rush lasts 15 to 30 minutes and
`
`isfollowed by a gadual descent back to nor-
`mal consciousness Jist afterthe rush, the user
`experiences a sudden clarity and intensifica-
`tion of perceptions seeing objectsas“brighter
`and crisper” and feeling an inner sensation of
`happiness with peopleseeming lovableexact-
`ly asthey are. At thispoint users usually take
`a booster dose of MDMA to prolong these
`feelings Unfortunately, booster dosesincrease
`toleranoetothedes' red effectsand an increase
`
`in the adverse effects of coming down.
`“ Bubble bursting’ refers to a buildup of
`anxiety,
`fear, stomach tightness name or
`panic instead of the expected rush.
`Thirty minutesto 3 hours after the initial
`“coming on,” or pe‘ception of enhanoed feel-
`ing, users experience a “plateau” phase of less
`intensefeelings Duringthe plateau, repetitive
`or tranoelike movements become extremely
`pleasurable,
`leading to long-lasting ecstatic
`gates of “trance dancing.” Rhabdomyolysis
`can easily occur during this phase of extended
`activity.
`The “coming down” phase occurs 3 to 6
`hoursafterinitia ingedion. Duringthisphase,
`feelingsof disappointment and other negative
`emotions (eg, depression,
`anxiety)
`can
`emerge, with slugg'slnness and res'dua effects
`lasting up to several days It may take up to 6
`to 7 hoursto fal asleep after returningto “nor-
`ma
`despite extreme exhaustion.
`
`Adverse effects of ecstasy
`Serious rhabdomyolysiscan occur with use of
`MDMA and other drugs (TABLE 1). Other side
`effectsof MDMA arelisted in TABLE2.
`
`In the short term, coming down is mi-
`ated with arelativedepletion of yotonin; the
`result iscaled the “Tuesday blues” a slugg'sln
`feeling lasting several daysafter ingestion.
`The long-term effects of MDMA use are
`being studied. Experts suspect
`that
`it may
`
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`the serotonin pathway with
`short-circuit
`repeated use over the long term, potentially
`causing a shortage of serotonin and subse
`quent depro-on. At the present time, how-
`ever, thisconcept is purely speculative.
`
`Management of overdose
`MDMA is metabolized in the liver to MBA,
`which isthen excreted in the urine; thus typ-
`ical urine drug teds may only detect MDA.
`Urine toxicology testing picks up wrta'n
`other drugsthat may have been simultaneous
`ly ingeded,
`including cannabis hallucino-
`gens phencydidine (PCP), or Simulants
`Assessing the serum blood alcohol
`level ca'i
`be useful. A monoclonal
`immunoassay for
`amphetamine or methamphetamine detects
`MDMA if the drug wastaken in large doses8
`Thin-layer chromatography ca1 also detect
`MDMA metabolites in the urine. Whenever
`
`anpheta‘nines are found on immunoa$ay
`screening tests, the results can be confirmed
`by gasd'iromatogaphy or mass spectrometry
`Management of acute heat
`injury in
`MDMA usersincludes rapid rehydration and
`core cooling. Management of rhdcdomyolysis
`involves rehydration, correction of electrolyte
`imbalances urine alkalinization, and use of
`furosernide as needed. Short-acting benzodi-
`azepinescan beadministered intravenously or
`intramuscularly for patientswith extreme ag-
`tation, penicreactions or seizures Neurolog'c
`merit and vital Sims should be checked
`frequently. Dantrolene may be useful in coun-
`teracting MDMA-associated muscle spasms
`beta-blockers calcium channel blockers or
`proca'nanide may be required to treat cardiac
`arrhythmias lfapatient seernslikelyto injure
`himself or others a quiet, dark setting with
`judicious use of benzodi azepi nee is i mperati ve.
`
`I GAM MA— HYDROXYBUTYRATE (GHB)
`
`GHB—also known asliquid ecstasy, easy lay,
`grievous bodily harm, cherry meth,
`soap,
`gowth hormone booster, gook, liquid X, liq-
`uid G, and liquid E—isa precursor of the neu-
`rotransmitter ganma aminobutyric acid
`(GA BA) that acts on the dopaminech sys
`tem. GHBisusJaily sold asaselty, dearliquid
`in small bottlesand istaken by the caoful. It
`iselsoavalableincaasileform. GHBisunde
`
`Adverse effects of MDMA
`
`(ecstasy) use
`
`Addiction (to concurrently used substances
`eg, amphetamines heroin, cocaine)
`Arrhythm'as
`Coagulopathy (dissem' nated intravasailar)
`Confusion
`Coma
`Death
`
`Dehydration
`Electrolyte imbalances
`Fatigue
`Heat injury (fatal, sometim referred to as
`“ wurday night fever”)
`l-lepatictoxicity
`Jaw—d enching
`Muscle spasrrs
`Pregnancy (unwanted)
`the
`mnal failure (acute)
`Tad1ycardia
`Teratogenicity
`
`
`
`tectable when mixed with beverages
`Developed as an adjunct to medhesia,
`GHB wasbelieved in the 19705to haveclini-
`
`cal val uein thetreatment of narcolepsr In the
`1980s it was used by wei g‘lt liftersto increase
`the metabolic rate. In the 1990s “blue nitro,”
`a GHB precursor, was used as a weight-loss
`preparation, while Serenity, mother GH B pre-
`cursor, was used by body builders GH B’s pur-
`ported medicinal value was eventually over-
`shadowed by its unpredictability: a given dose
`could completdy anesthetize one patient and
`have no effect on awother.
`
`How GHB works
`
`GH B’s wntral nervous system effects include
`mediation of sleep cycles temperature regila
`tion, cerebral gucose metabolism and blood
`flow, memory, a1d emotional control.11 The
`on$t of action iswithin 15 to 60 minutes and
`effectslast from 1 to 3 hours The half-life is
`
`27 minutes with elimination by expired
`breath ascarbon dioxide.
`
`GHB‘s effects
`
`vary greatly
`
`from person
`
`to person
`
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`CLEVELAND CLINIC JOURNAL OF MEDICINE
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`VOLUME 58 - NUMBER 6
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`ILLICIT DRUG USE
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`
`Desi red effects of GHB
`
`I KEI'AMINE
`
`Young people take GHB to experience
`euphoria, dis'nhibition, and sexua enhanc-
`ing effects without an appreciable hang-
`over.12
`
`Adverse effects of GHB
`
`The concentration may vary, so the response
`is idiosyncratic. Patients may experience
`either mydrias'sor miosis another indication
`of the inconsistent response from person to
`person.
`In severe cases the classic triad of
`symptoms includes coma bradycardia and
`myoclonus Halucinationscan also occur.
`As the patient starts to recover, “emer-
`gence phenomena’ can occur, characterized
`by myoclonicjerking motions trans' ent con-
`fusion, and combativenefi followed by rapid
`recovery of consciousness“,12
`Other effects include delusions depres
`s'on, atered mental status apnea, hypoten-
`s'on, nausea vomiting, vertigo,
`respiratory
`distress, transient metabolic acidosis loss of
`airway reflexes ataxia nystagnus aggs-ve
`behavior, somnolence, anterogade amnes'a
`and coma
`
`Adverse effects are potentiated by aoo
`hol, ketamine, benzadiazepines, major tran-
`quilizers opiates anticonvulsants and over-
`thecounter cold and sleep medicines All of
`the above can e<acerbate resairatory depres
`sion. Use with methamphetamine increases
`the risk of seimre.
`
`Management of GHB overdose
`Management of GHB overdose oons'sts of
`supportive therapy, including prevention of
`aspiration.
`Intravenous fluids and oxygen
`may be required, and atropine should be used
`in patients with persistent symptomatic
`bradycardia In severecasss rapid intubation
`with succinylcholine paraysis may be
`required for advanced airway protection.13 If
`abuse of multiple drugs is suspected, orogas
`tric lavage and administration of activated
`charcoa with sorbitol isrecommended. lfthe
`
`intoxicated at 6 hours after
`is Sill
`patient
`ingestion, hospital admission is warranted.
`Otherwise,
`if aert, responsive and normal
`on physical examination 6 hours after inges-
`tion, the patient can be discharged from the
`emergency room.
`
`Ketanine (specia K, vitamin K, new ecstasy,
`ketalar, ketay'ect, psychedelic heroin, and
`super K) isa shorter-acting, less potent ater-
`nativeto PCP It isused by veterinaiansasan
`anesthetic,
`is available in both liquid and
`powder formsand hasa bitter taSe. Theliquid
`form is usualy ingested orally or intravenous
`Iy. In White powder form it iseither snorted by
`itself or smoked with ma'ijuana or tobacco.
`The powder can be made from the liquid by
`gently boiling on a stove or in the microwave.
`Dose-to-dose variability in effects is com-
`mon, and the effects are potentiated by doc
`hol, barbiturates opiates GH B, and vdium. If
`taken intranuscularly, effects oocur within 2
`minutes If ta<en orally, effects oocur within
`15 to 20 minutes or sooner on an empty
`Somach.
`If taken intranasally,
`the dose is
`repeated every 5 minutes until
`the des'red
`effectsare achieved.
`
`Desi red effects of ketamine
`Effectslast 2 to 3 hours Low doseslead to feel-
`
`ings of relaxation, and high doses bring on a
`sensation of a near-death experience (known
`asthe“K—hole”) and lossof sense of time and
`identity. ”K-land” refersto hallucinations and
`visual distortions The user feels no pain, a
`Sate that can lead to unintentional
`injuries
`the user may not be aivare of until he or she
`oomesdown.
`
`Adverse effects of ketamine
`
`Short-term physicd effects include tachycar-
`dia hypertension,
`impaired motor function,
`respiratory deprsslon, bronchodilation, pap-
`illay dilation, and nausea. Short-term psy-
`cholog'c effects include dissociation, depres
`s'on,
`recurrent
`flashbacks, delirium, and
`amnes'a.
`
`Long-term adverse. effects a‘e currently
`unknown,
`but brain damage has been
`observed in animai studies Persons wlno use
`
`ketamine while taking antibiotics (eg,
`ofloxacin), anticholinergics antipsychotics
`bupropion (Wellbutrin and Zyban), caffeine,
`or GHB increase their risk of seizure. Under
`
`the drugs short-term effects the user may
`remain so immobile as to become hypother-
`mic.
`
`High doses
`of ketamine
`
`can produce
`‘K-hole,‘
`a near-death
`
`experience
`
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`Management of ketamine overdose
`Neuroleptic drugs are ineffective in control-
`ling the unpleagnt mental awd visua side
`effects of ketanine.14 The clinician should
`
`watch for oversedation, protectingtheanA/ays
`asnecessary
`
`I ROI-IYPNO.
`
`Rohypnol, (the date rape drug, ruffi es roofi es
`rouches the forget pill) islicensed in Europe,
`Asia and Latin America as an anti-seizure
`drug.
`It
`is a benzodiazepine 10 times more
`potent tha'i diwpan (Valium).
`It is sold as
`individualywraoped tabletsthat are colorless
`odorless, acid tasteless when mixed in bever-
`399$
`
`Desired effects of rohypnol
`Des' red effectsi ncl ude disi nhi bition, annes'a
`and muscle relaxation, but individua effects
`vary.
`
`Adverse effects of rohypnol
`Adverse effects include sedation, reqoiratory
`depruu on,
`impaired motor coordination,
`confusion, memory loss hallucinations and
`potential overdose when combined with alco-
`hol. Paradoxicai ly, it may cause aggo-veness
`in some cases
`
`Management of rohypnol overdose
`Rohypnol is not detectablewith routine urine
`toxicology screening. Ainivay protection and
`blood preaire control may be warranted.
`Midazalan (Versed), used asa sedative before
`endoscopy, cat be uad in severe cases to
`reverse benzodiazrepine effects but
`longer
`observation would be indicated.
`
`I HERBAL BJSI'ASY
`
`Herbal ecstasy (ma humg, ephedra) isused as
`astimulaqt or aweigit-Iossagent and isaval-
`able at many health food Sores and by mail
`order from sources advertised in drug culture
`magazines lt isa1 ingredient in someChinese
`herbal medicationsand in nutritional supple-
`mentssuch asMetabolift a1d Metabolife 356.
`
`A 300-mg dose of ephedra isequivalent to 30
`mg of ephedrine. Ephedrine isfound in many
`over-the-oounter cold prepaations Neither
`
`ephedra nor its extracted form ephedrine are
`regulated by the US Food and Drug
`Administration.
`
`Desired effects of herbal ecstasy
`The effects of herbai ecstasy last 3 to 4 hours
`when taken orally. Three tablets taken
`together have a1 effect similar to a‘npheta
`mines or a lage dose of caffeine.
`
`Adverse effects of herbal ecstasy
`Adverse effects include tachycardia hyper-
`tens' on, eroke, seizure, myocardia infarction,
`a1d death. The doses needed to producethese
`effects are not known. These substances are
`
`regulated by the Food and Drug
`not
`Administration, and it ishad to know exact-
`ly how much of any given substancea product
`oonta' ns
`
`Management of overdose
`An overdose of herbal ecstasy may be associ-
`ated with restlessness muscle spasms, tachy-
`cardia, dry throat, and cold extremities
`Neither ephedra or ephedrine should be used
`by peoplevvith cardiac probl ems or high blood
`prewre. Hypertension in persons who have
`overdosed on herbal ecstasy may reqoond to
`the use of benzodiazepi nesto decrease anxiety.
`Nitropru$de should be used in hypertensive
`was
`
`I MEI'HAMPHEI'AMINE
`
`Methamphetamine (ice, crystal meth, speed,
`tweak, crank, gass, ortina) isahigily addic-
`tive Simulaqt that causesthe release of large
`anounts of dopamine, enhancing mood and
`body movement. It is sold either as a white
`powderthat istaken orally, intrmasaly intra
`venousy, or rectaly, or as a clea', crysa-
`shaoed “rock” that is heated and smoked like
`crack cocaine The smoked form iscaled ice,
`crystal, and gass
`
`Desired effects of methamphetamine
`Smoking and intravenous use g've a rush
`described asa1 intense, very pleasurable $n-
`sation that laflsafew minutes lntrmasa and
`
`orai use do not producethisrush, but rather a
`“high.” Effects occur within 3 to 5 minutes
`with intra'iasal use and within 15 to 20 min-
`
`Metham-
`
`phetamine
`
`isa highly
`addictive
`
`stimulant
`
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`
`CLEVELAND CLINIC JOURNAL OF MEDICINE
`
`VOLUME 58 - NUMBER 6
`
`JUNE 2001
`
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`
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`

`

`ILLICIT DRUG USE
`
`ROME
`
`uteswith oral use, and can last up to 24 hours
`
`Adverse effects of methamphetamine
`Adverse effects of methamphetamine use
`incl ude avvide variety of physical and psycho
`log'cal effects eg, wakefulness increased phys
`icai activity (a hyperaien state, restlessness),
`decreased appetite, headache, mydrias's sen-
`sation of hair “standing on end,” vasoconstric—
`tion of extremities dry mouth, hyperreflexia
`tremors tachycardia, hypertension, palpita-
`tions cardiac arrhythmias ca'diomyopathy,
`stroke, hyperthermia seizures, euphoria irri-
`tability,
`insomnia, anxiety, hallucinations
`paranoia psychosis and death.
`Methamphetamine may cause degenera-
`tion of neurons containing the neurotrens
`mitter dopamine, with damage of these neu-
`rons known to be the underlying cause of the
`motor di3urbances $en in Parkinson dis-
`ease.
`
`Management of methamphetamine overdose
`Effects of methampheta'ninetend to last 5 to
`10 hours The drug is metabolized to amphet-
`anine. Urine toxicology screening may pick
`up both methamphetamine and ampheta
`mine. Gas chromatogaphy and mass spec-
`trometry can differentiate methamphetamine
`from amphetamine
`In case of overdose, haoperidol can be
`used to control ag'tation, and benzodiampines
`can be used to control seizures Hypertension
`can be managed with intravenous betablod<—
`ers Cadiac monitoring and precautions to
`prevent seizure are usually indicated. Some
`patients may require ainrvay protection.
`
`I OTHER CLUB DRUGS
`
`GHB precursors
`A commonly found GH B precursor isgemma-
`butyrolactone (GBL), as.) known as blue
`nitro, gammaG,
`renewtrient,
`reviverent.
`GBL is an organic solvent used for cleaning
`circuit boards stripping paint, or flavoring soy
`products It acts like GHB but has a slower
`onset 31d a longer duration. Adverse effects
`incl ude respiratory depress on and ca'diacdys
`rhythmia It is metdaolized in the liver into
`GHB but can also be made into GHB using
`home kits Other precursors to GHB include
`
`tetramethyl ene g ycol and 2(3H )-furanone di-
`hydro.
`
`Smart drinks
`
`In addition to alcohol, marijuana cocaine,
`and amphetamines other substances associ at-
`ed with the rave subculture are stimulants
`
`called “smart drinkS’ (see“The rave scene a
`closer look, page 542), dso cdled “power
`drinks”which are used to prevent dehydra
`tion. They are sold at both ravesadd nutrition
`stores and come in bottleeor cans or as pow-
`dersor capsules They may conta' n ma huang,
`caffeine, gua'ana (a stimulant simila to caf-
`feine), g'nseng, amino acids taurine, sugars
`tryptopha'i, and high doses of B and C vita-
`mins
`
`Go—go drinks
`Go-go drinks similar to power drinks areaso
`sold at ravesadd contain g'nseng, yohimbine,
`and guara'ia They are marketed as”Viaga for
`women.” They ae used to boost energy levels
`to increase stamina to quench thirst, and to
`enhance concentration. Mos contain Simu-
`
`la'its Ta<en in excessthey can cause nausea,
`lossof appetite, insomnia, tachycardia visual
`and wsory impairment, and bladder and uri-
`nary tract discomfort. People with heert or
`kidney disease hypertension, hypotens'on,
`asthma and diabetes mellitus should not use
`them.
`
`I MANAGING DESIGNER DRUG ABUE
`ADDITI O\|AL MS DERA'I'I ONS
`
`Urine and serum toxicology screens may not
`be able to detect club drugs For example,
`urine screening does not detect MDMA,
`though it does detect its metabolite, MDA.
`Urine scrwning does not detect LSD,
`inhalants alcohol, benzodiazepines such as
`alprazolan (Xadax) and lorazepan (Ativan),
`and methylphenidate (Ritalin). Thin—layer
`chromatography can be requested, specifying
`susoected drugsbased on the history and phys
`icd exemi nation.
`
`The patient should be placed in awarm,
`dark room. When possible, the patient and
`friends should be questioned asto what drugs
`were ingested and in what form.
`In crisis situations iabilize the patient
`
`Stimulant-
`
`containing
`drinks are used
`
`to prevent
`
`dehydration
`
`548
`
`CLEVELAND CLINIC JOURNAL OF MEDICINE
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`
`VOLUME 68 - NUMBER 6
`
`JUNE 2001
`
`PAR1022
`
`CBM of US. Patent No. 7,668,730
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`
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`

`

`Ocular effects
`
`Cardiovascular effects
`
`of commonly abused drugs
`
`of commonly abused drugs
`
`Conjunctival injection
`Lysergic acid diethylan‘ide (LSD)
`Marijuana
`M iosis
`Alcohol
`Barbiturates
`
`Benzodiazepines
`Opiates
`Phenwdidine (PCP)
`
`M yd riasis
`Alcohol or opiate withdrawal
`Amphetan'i nos/stimulants
`Cocaine
`Gutethim'de
`Jmson weed
`LSD
`
`Nyst ag m u 5
`Al oohol
`Barbiturates
`Benzodiazepi nos
`Inhalants
`PCP
`
`Tearing (excessive lacrimation)
`Inhalants
`LSD
`
`Opiate withdrawal
`
`
`A rrh yt h m i a
`Anphetamines/stirmlants
`Cbcai ne
`Inhalants
`
`Opiates-
`F’nencyd idi ne (FCF)
`
`Hypertension
`An‘phetami nes/sti milants
`Cocaine
`
`Lysergic acid diethylamide (LSD)
`Marijuana
`PCP
`Wthdrawal from alcohol, barbiturates
`benzodiazepi has
`
`Hy p 0t e n si 0 n
`Barbiturates
`
`Marijuana (ort hostati c hypotensi on)
`Opiates
`Tachycardia
`Anphetamines’aimulants
`Cocaine
`LSD
`
`Marijuana
`PCP
`Wthdrawal from alcohol, barbiturath
`benzodiazepi nos
`
`while getting asmuch history aspossiblefrom
`both patient and accompanying peers Fear
`and concern for a friend may get
`them to
`share more details than they would otherwise
`rel/ea at a risk of incriminating themselves
`Be nonjudg‘nenta but informative, and avoid
`lecturing the patient.
`If the patient is comatose, the “A see
`aoply: ainNay, breathing, circulation. TABLE3
`liistheoculafindingsassaciated with useof
`different drugs, and TABLE 4 lists cardiovascular
`findings
`
`I HOIIVTOSTAYINFORIVIED
`
`If the patient isateenager, quedioning needs
`to be“adolesca1t-sa"isitive,” establishing con-
`fidentiaity yet definingthelimitsof that con-
`fidentiality: “I will keep every