REVIEW
`
`ELLEN S. ROME, MD, MPH
`ELLEN S. ROM E, MD, MPH
`Head, Section of Adolescent Medicine,
`Head, Section of Adolescent Medicine,
`Cleveland Clinic
`Cleveland Clinic
`
`n ABSTRACT
`I ABSTRACT
`Illicit drug use by young people has changed in the last
`Illicit drug use by young people has changed in the last
`decade, with the increasing use of “designer” or “club”
`decade, with the increasing use of “designer” or“ club’’
`drugs such as ecstasy. Keeping abreast of current trends in
`drugs such as ecstasy. Keeping abreast of current trends in
`illicit drug use prepares the primary care clinician to
`illicit drug use prepares the primary care clinician to
`recognize the clinical effects of drug use, to manage drug
`recognize the clinical effects of drug use, to manage drug
`emergencies, and to detect addictive behavior. Today’s
`emergencies, and to detect addictive behavior. Today’s
`widely used drugs, their street names, their effects, and how
`widely used drugs, their street names their effects, and how
`to manage overdoses are reviewed.
`to manage overdoses are reviewed.
`n KEY POINTS
`I KEY POINTS
`Popular “designer” drugs include ecstasy, gamma-
`Popular “designer” drugs include ecstasy, gamma-
`hydroxybutyrate (GHB), Rohypnol, ketamine, herbal ecstasy
`hydroxybutyrate (GHB), Rohypnol, ketamine, herbal ecstasy
`(ma huang, ephedra), and methamphetamine.
`(ma huang, ephedra), and methamphetamine.
`
`It’s a rave new world: Rave culture
`It's a rave new world: Rave culture
`and illicit drug use in the young
`and illicit drug use in the young
`N
`EW AND POTENTIALLY dangerous illicit
`EW AND POTENTIALLY dangerous illicit
`drugs are popular among young people
`dmss are popular among young people
`today. Relatively little is known about the
`today. Relatively little is known about the
`short-term and long-term adverse effects of
`short-term and long-term adverse effects of
`these drugs or how to test for them.
`these drugs or how to test for them
`A major trend since the early 1990s has
`A major trend since the early 1990s has
`been the use of “designer” or “club” drugs such
`been the use of ”designer” or ”cl
`” drugs such
`as “ecstasy” at raves—all-night dance parties
`as ”ecsta.sy” at raves—all-night dance parties
`with marathon dancing to electronic “techno”
`with marathon dancing to electronic ”techno”
`music. Use of the designer drugs gamma-
`music. Use of the designer drugs gunma-
`hydroxybutyrate (GHB), Rohypnol, and keta-
`hydroxybutyrate (GHB), Rohypnol, and keta-
`mine, also called “date rape” drugs, is wide-
`mine, also called ”date rape” drugs, is wide-
`spread enough to have prompted Congress to
`spread enough to have prompted Congre$ to
`adopt the Drug-Induced Rape Prevention and
`adopt the Drug-Induced Rape Prevention and
`Punishment Act of 1996, which increased
`Punishment Act of 1996, which increased
`Federal penalties for use of any controlled sub-
`Federal penalties for use of any controlled sub-
`stance to aid in sexual assault (see “Date rape
`stance to aid in sexual a$ault (see "Date rape
`drugs: What parents should know,” page
`drugs: What parents should know” page
`551).
`551).
`Drug abuse leads to short-term and long-
`Drug abuse leads to short-term and long-
`term health problems. Keeping abreast of
`term health problems Keeping abreast of
`trends in illicit drug use enhances the clini-
`trends in illicit drug use enhances the clini-
`cian’s ability to recognize and manage overdos-
`cian's ability to recognize and manage overdos-
`es and to pick up clues of addiction in young
`es and to pick up clues of addiction in young
`patients. This article briefly reviews the scope
`patients This article briefly reviews the scope
`of illicit drug use in young people and the most
`of illicit druguse in young people and the most
`popular designer drugs.
`popular designer drugs
`
`Designer drugs are easily obtainable and affordable at
`Designer drugs are easily obtainable and affordable at
`raves—all-night dance parties with marathon dancing to
`raves— all-night dance parties with marathon dancing to
`electronic “techno” dance music.
`electronic“ techno” dance music.
`
`Other substances associated with rave culture include
`Other substances associated with rave culture include
`“smart drinks” sold for rehydration; these may contain ma
`“smart drinks” sold for rehydration; these may contain ma
`huang, caffeine, guarana (a caffeine-like stimulant), and
`huang, caffeine, guarana (a caffeine-like stimulant), and
`ginseng.
`ginseng.
`
`When questioning teens and young adults about drug use,
`When questioning teens and young adults about drug use,
`a non-confrontational approach helps. The clinician needs
`a non-confrontational approach helps. The clinician needs
`to establish confidentiality and to define the limits of that
`to establish confidentiality and to define the limits of that
`confidentiality.
`confidentiality.
`
`PATIENT INFORMATION
`PATIENT INFORMATION
`Date rape drugs: What parents should know, page 551
`Date rape drugs:What parents should know, page 551
`Wockhardt 1022
`
`n THE SCOPE OF DRUG ABUSE
`I THE SCOPE OF DRUG ABUSE
`IN THE YOUNG
`IN THE YOUNG
`
`Illicit drug use continues to be prevalent
`Illicit drug use continues to be prevalent
`among young people. Some of the drugs used
`among young people. Some of the drugs used
`are familiar (alcohol, marijuana) and some are
`are familiar (alcohol, marijuana) and some are
`newer and perhaps unfamiliar to many of us.1
`newer and perhaps unfamiliar to many of us1
`The percentage of 8th graders reporting
`The percentage of 8th graders reporting
`illicit drug use doubled from 11.3% in 1991 to
`illicit druguse doubled from 11.3% in 1991 to
`21.4% in 1995.2 Then, after 1 or 2 years of
`21.4% in 1995.2 Then, after 1 or 2 years of
`decline in the late 1990s, the use of marijuana,
`decline in the late 1990s, the use of marijuana,
`amphetamines, tranquilizers, heroin, and alco-
`amphetamines, tranquilizers, heroin, and alco-
`
`CLEVELAND CLINIC JOURNAL OF MEDICINE
`VOLUME 68 - NUMBEFI6
`JUNE 2001
`CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001
`Downloaded from www.ccjm.org on June 4, 2014. For personal use only. All other uses require permission.
` on June 4, 2014. For personal use only. All other uses require permission.
`www.ccjm.org
`Downloaded from
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`541
`
`Wockhardt 1022
`
`

`
`ILLICIT DRUG USE
`ILLICIT DRUG USE
`
`ROME
`ROME
`
`The rave scene: A closer look
`The rave scene: A closer look
`R
`AVES ARE PARTIES with loud, electronic “tech-
`“Circuit parties” are weekend-long parties or
`AVES ARE PARTIES with loud, electronic ”tech—
`”Circuit parties” are weekend—long parties or
`no-rock” music, laser light shows, and all-
`raves with a homosexual orientation, involving
`norock” music, laser light shows, and all-
`raves with a homosexual orientation,
`involving
`night dancing. They are held in clandestine loca-
`5,000 to 20,000 people. Partygoers travel from
`night dancing They are held in clandestine loca-
`5,000 to 20,000 people. Partygoers travel from
`tions, including warehouses, nightclubs, and farm
`event to event, with some of these parties being
`tions, including warehouses, nightclubs, and farm
`event to event, with some of these parties being
`fields. They first became popular in Great Britain in
`substantially linked economically to fundraising or
`fields They first became popular in Great Britain in
`substantially linked economically to fundraising or
`the late 1980s.
`cultural events.
`the late 1980s
`cultural events
`Alcohol is not sold at many raves, but designer
`In Montreal, this circuit has been estimated to
`In Montreal, this circuit has been estimated to
`Alcohol is not sold at many raves, but designer
`and other drugs are obtainable and affordable. In
`be the second largest money maker for their tourism
`and other drugs are obtainable and affordable. In
`be the second largest money maker for their tourism
`addition, “power drinks” are usually sold: these are
`industry.
`addition, ”power
`are usually sold these are
`industry
`fruit juice mixed with amino acid powders and B
`fruit juice mixed with amino acid powders and B
`vitamins to replenish fluids lost during strenuous
`vitamins to replenish fluids lost during strenuous
`marathon dancing.
`marathon dancing
`
`SPREADING THE WORD
`SPREADING THE WORD
`Two to three days before a rave, information about
`Two to three days before a rave, information about
`the location is disseminated via the Internet (eg,
`the location is disseminated via the Internet (eg
`links accessible from www.dancesafe.org), fliers, or
`linl<s accessible from www.dancesafe. org), fliers, or
`word of mouth. Raves are sometimes advertised
`word of mouth. Raves are sometimes advertised
`under alluring names, such as “Rave New World” or
`under alluringnames, such as "Rave NewWorld” or
`“Save the Rave Forest.”7 Raves attract mainly peo-
`”Save the Rave Forest.”7 Raves attract mainly peo-
`ple 16 to 21 years old, but younger teens and some
`ple 16 to 21 years old, but younger teens and some
`adults also frequent these parties. A single rave in
`adults also frequent these parties A single rave in
`Ohio attracted young people from a five-state area.
`Ohio attracted young people from a five-state area.
`Some rave fans go from city to city in search of the
`Some rave fans go from city to city in search of the
`next best rave.
`next best rave.
`
`OTHER TYPES OF RAVES
`OTHER TYPES OF RAVES
`“Bush parties” are outdoor parties often with a
`”Bush parties” are outdoor parties often with a
`sports focus; alcohol use at these events tends to
`sports focus; alcohol use at these events tends to
`exceed drug use.
`exceed drug use.
`
`ATTEMPTS TO MAKE DRUG USE AT RAVES SAFER
`A1'|'EM PTSTO M AKE DRUG USE AT FIAVES SAFER
`Drug safety check stations. Because the
`Drug safety check stations. Because the
`designer drugs sold at raves are not always pure,
`designer drugs sold at raves are not always pure,
`many raves now feature stations where users can
`many raves now feature stations where users can
`have the purity of their drugs checked, without the
`have the purity of their drugs checked, without the
`risk of being arrested for possession. This is an effort
`risk of being arrested for possession. This is an effort
`to increase the safety of illicit drug use by letting
`to increase the safety of illicit drug use by letting
`users know exactly what they are taking. Many
`users know exactly what they are taking Many
`local police departments arrest only those individu-
`local police departments arrest only those individu-
`als caught selling drugs.
`als caught selling drugs
`Safe spaces. In Montreal, physicians often go
`Safe spaces. In Montreal, physicians often go
`to raves to create “safe spaces” for medical triage
`to raves to create ”safe spaces” for medical triage
`and urgent referral to local emergency rooms. This
`and urgent referral to local emergency rooms. This
`practice is one of damage control rather than pri-
`practice is one of damage control rather than pri-
`mary prevention and has been controversial
`mary prevention and has been controversial
`among adolescent medicine professionals. On one
`among adolescent medicine professionals. On one
`hand, this practice has prevented deaths from
`hand,
`this practice has prevented deaths from
`overdose and has provided a source of education;
`overdose and has provided a source of education;
`but on the other hand, it does little to decrease
`but on the other hand, it does little to decrease
`actual drug use.
`actual drug use.
`
`hol among 8th, 10th, and 12th graders stopped
`hol among 8th, 10th, and 12th graders stopped
`declining and leveled off from 1998 to 1999,
`declining and leveled off from 1998 to 1999,
`according to the National Institute on Drug
`according to the National Institute on Drug
`Abuse’s 1999 Monitoring the Future study.3
`Abuse’s 1999 Monitoring the Future study.3
`
`Alcohol
`Alcohol
`Alcohol is the most widely used drug among
`Alcohol is the most widely used drug among
`young people, with four out of every five stu-
`young people, with four out of every five stu-
`dents having consumed alcohol by the end of
`dents having consumed alcohol by the end of
`high school, and 52% by the 8th grade.3
`school, and 52% by the 8th grade.3
`Almost two thirds of 12th graders and one
`Almost two thirds of 12th graders and one
`fourth of 8th graders reported having been
`fourth of 8th graders reported having been
`drunk at least once.3 Binge drinking rates
`drunk at
`least once.3 Binge drinking rates
`have leveled off in the past few years, just as
`have leveled off in the past few years, just as
`designer drugs started gaining in popularity.
`designer drugs started gaining in
`Alcohol-drug combinations. A popular
`Alcohol-drug combinations. A popular
`trend is to combine alcohol with over-the-
`trend is to combine alcohol with over-the-
`Wockhardt 1022
`
`counter drugs. One example is a “roboshot”—
`counter drugs One example is a ”roboshot”—
`1 to 2 ounces of Robitussin DM chugged with
`1 to 2 ounces of Robitu$in DM chuged with
`a 12-ounce beer. This allegedly produces a
`a 12-ounce beer. This allegedly produces a
`“buzz” equivalent to a six-pack of beer, with-
`“buzz” equivalent to a six-pack of beer, with-
`out any hangover.
`out any hangover.
`
`Marijuana
`M ariiuana
`Marijuana is the second most widely used drug
`Marijuana is the secondmost widelyused drug
`among young people: 17% of 8th graders, 32%
`among young people: 17% of 8th graders, 32%
`of 10th graders, and 38% of 12th graders
`of 10th graders, and 38% of 12th graders
`reported having used it at least once, and 1.4%
`reported havingusedit at least once, and 1.4%
`of 8th graders, 3.8% of 10th graders, and 6.0%
`of 8th graders, 3.8% of 10th graders, and 6.0%
`of 12th graders reported daily use.3
`of 12th graders reported daily use.3
`
`Inhalants
`Inhalants
`For the past 5 years, the use of inhalants by
`For the past 5 years, the use of inhalants by
`students surveyed in the Monitoring the
`students surveyed in the Monitoring the
`
`542
`
`JUNE 2001
`VOLUME 68 - NUMBER 6
`CLEVELAND CLINIC JOURNAL OFMEDICINE
`CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001
`Downloaded from www.ccjm.org on June 4, 2014. For personal use only. All other uses require permission.
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`Wockhardt 1022
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`

`
`Future Study has steadily declined, with 10%
`Future Study has steadily declined, with 10%
`of 8th graders, 7% of 10th graders, and 6% of
`of 8th graders, 7% of 10th graders, and 6% of
`12th graders reporting use at least once during
`12th graders reportinguse at least once during
`1999. The data for the year 2000 show
`1999. The data for the year 2000 show
`inhalant use continues to be more prevalent
`inhalant use continues to be more prevalent
`in younger teens.4
`in younger teens4
`Inhalants are readily accessible. A wide
`Inhalants are readily acce$ible. A wide
`range of common household products are
`range of common household products are
`used, including glue, solvents, butane, gaso-
`used, including glue, solvents, butane, gaso-
`line, and aerosols.
`line, and aerosols
`
`Anabolic steroids
`Anabolic steroids
`Among young people, use of anabolic steroids
`Among young people, use of anabolic steroids
`is more common in boys than in girls. Steroid
`is more common in boys than in girls Steroid
`use increased in 1999, with 2.5% of 8th
`use increased in 1999, with 2.5% of 8th
`graders and 2.8% of 10th graders using
`graders and 2.8% of 10th graders using
`steroids.3 These rates almost doubled com-
`steroids3 These rates almost doubled corn-
`pared with 1998 rates of 1.6% and 1.9%,
`pared with 1998 rates of 1.6% and 1.9%,
`respectively, and fewer 12th graders consid-
`respectively, and fevser 12th graders consid-
`ered steroids as risky as they did the previous
`ered steroids as
`as they did the previous
`year. The 2000 Monitoring the Future study4
`year The 2000 Monitoring the Future study4
`showed that between 1999 and 2000 the use
`shovsed that betvseen 1999 and 2000 the use
`of anabolic steroids increased among 10th
`of anabolic steroids increased among 10th
`graders.
`graders
`
`Designer drugs
`Designer drugs
`A number of drugs are used by teens and
`Anurnberofdrugsareusedbyteensand
`young adults who frequent raves, bars, and
`young adults who frequent raves, bars, and
`nightclubs, where they are relatively easy to
`nightclubs, where they are relatively easy to
`obtain and affordable. Popular designer drugs
`obtain and affordable. Popular designer drugs
`currently include:
`currently include:
`• Ecstasy, the common name for 3-4 meth-
`0 Ecstasy the common name for 3-4 rneth-
`ylenedioxymethamphetamine (MDMA),
`ylenedioxyrnethamphetamine (MDMA),
`also called “Adam” and “XTC”
`also called ”Adam” and ”XTC”
`• The date rape drugs GHB, flunitrazepam
`0 The date rape drugs GI-IB, flunitrazepam
`(known mainly by its brand name,
`(known mainly by its brand name,
`Rohypnol), and ketamine
`Rohypnol), and ketamine
`• Herbal ecstasy, another name for ma
`0 Herbal ecstasy, another name for ma
`huang or ephedra
`huang or ephedra
`• Methamphetamine.
`0 Methamphetamine.
`The makeup of these designer drugs, as
`The makeup of these designer drugs, as
`well as their desired effects, their short-term
`well as their desired effects, their short-term
`and long-term adverse effects, and how to
`and long-term adverse effects, and how to
`manage overdose are discussed later in this
`manage overdose are discu$ed later in this
`article.
`article.
`Ecstasy. In a random survey of illicit drug
`Ecstasy. In a random survey of illicit drug
`use in undergraduates attending Tulane
`use in undergraduates attending Tulane
`University in 1990, use of ecstasy was report-
`University in 1990, use of ecstasy was report-
`ed by 24% of those surveyed.5 In 1996, 5% of
`edby24% of those surveyed_5 In 1996, 5% of
`US 16-year-olds reported ecstasy use.6
`US 16-year-olds
`reported ecstasy use.6
`According to the 1999 Monitoring the Future
`According to the 1999 Monitoring the Future
`Study,3 4.4% of 10th graders and 5.6% of 12th
`Study,3 4.4% of 10th graders and 5.6% of 12th
`Wockhardt 1022
`
`graders reported using ecstasy in the past year.
`graders reported using ecstasy in the past year.
`The 2000 Monitoring the Future Study
`The 2000 Monitoring the Future Study
`showed that the use of ecstasy by all three
`shovsed that the use of ecstasy by all three
`groups increased.4
`groups increased.4
`GHB is a date rape drug either intention-
`GHB is a date rape drug either intention-
`ally used or surreptitiously administered to
`ally used or surreptitiously administered to
`incapacitate a victim, preventing her or him
`incapacitate a victim, preventing her or him
`from resisting sexual assault. As with other
`from resisting sexual a$ault. As with other
`date rape drugs, its use is not confined to date
`date rape drugs, its use is not confined to date
`rape situations.
`rape situations
`No data on the prevalence of its use are
`No data on the prevalence of its use are
`available as of this writing. Nevertheless,
`available as of this writing Neverthele$,
`the problem of GHB, Rohypnol, and keta-
`the problem of GHB, Rohypnol, and keta-
`mine use received sufficient national atten-
`mine use received sufficient national atten-
`tion to prompt Congress to pass a law
`tion to prompt Congress to pass a law
`increasing penalties for using drugs in sexual
`increasing penalties for using drugs in sexual
`assault.
`assault.
`Rohypnol is an anti-seizure drug avail-
`Rohypnol is an anti-seizure drug avail-
`able in Europe but not in the United States.
`able in Europe but not in the United States
`Rohypnol use showed a small decline in
`Rohypnol use showed a small decline in
`1999, with 0.5% of 8th graders and 1.0% of
`1999, with 0.5% of 8th graders and 1.0% of
`10th and 12th graders reporting use.3
`10th and 12th graders reporting use.3
`Rohypnol may be lethal when combined
`Rohypnol may be lethal when combined
`with alcohol.3,7
`with alcohol.37
`Ketamine is a rapid-acting general anes-
`Ketamine is a rapid-acting general anes-
`thetic used as an alternative to cocaine and
`thetic used as an alternative to cocaine and
`usually snorted. No data on the prevalence
`usually snorted. No data on the prevalence
`of ketamine use are available as of this writ-
`of ketamine use are available as of this writ-
`ing.
`ins
`
`n ECSTASY
`I ECSTASY
`
`Ecstasy (MDMA, XTC, X, E, Adam) is a syn-
`Ecstasy (MDMA, XTC, X, E, Adam) is a syn-
`thetic, psychoactive, hallucinogenic drug,
`thetic, psychoactive, hallucinogenic drug
`first synthesized in Germany by Merck in
`first synthesized in Germany by Merck in
`1914 to facilitate communication during psy-
`1914 to facilitate communication during psy-
`chotherapy.8 It is an amphetamine analogue
`chotherapy.3 It is an amphetamine analogue
`and a selective serotonergic neurotoxin.
`and a selective serotonergic neurotoxin.
`Experimentation in humans has been traced
`Experimentation in humans has been traced
`back only to the early 1970s.9 Its use was
`back only to the early 1970s9 Its use was
`criminalized in the United States in 1985,9 by
`criminalized in the United States in 1985,9 by
`which time it had jumped from the psychia-
`which time it had jumped from the psychia-
`trist’s couch to the dance floor.
`trist’s couch to the dance floor.
`Much of what is sold as ecstasy is not pure
`Much of what is sold as ecstasy is not pure
`MDMA, but may be any combination of 3,4-
`MDMA, but may be any combination of 3,4-
`methylenedioxyamphetamine (MDA, the
`rnethylenedioxyamphetarnine (MDA,
`the
`love pill, the love drug, or speed for lovers),
`love pill, the love drug or speed for lovers),
`N-ethyl-methylendioxyamphetamine (MDE,
`N-ethyl-rnethylendioxyamphetarnine (MDE,
`Eve), lysergic acid diethylamide (LSD),
`Eve),
`lysergic acid diethylamide (LSD),
`amphetamine, caffeine, heroin, or lactose.
`amphetamine, caffeine, heroin, or lactose.
`MDE produces effects similar to those of
`MDE produces effects similar to those of
`MDMA but turns the subject inwards.
`MDMA but turns the subject inwards
`
`GHB, Rohypnol,
`GHB, Rohypnol,
`and ketamine
`and ketamine
`are the date
`are the date
`rape drugs
`rape drugs
`
`JUNE 2001
`CLEVELAND CLINIC JOURNAL OF MEDICINE
`VOLUME 68 - NUMBER 6
`CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001
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`www.ccjm.org
`Downloaded from
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`543
`543
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`

`
`ILLICIT DRUG USE
`
`ROME
`
`T A B L E 1
`Commonly abused drugs
`associated with serious heat injury
`or rhabdomyolysis
`
`
`
`Amphetamines
`Cocaine
`MDMA (ecstasy)
`Methamphetamine (crystal meth, ice)
`Phencyclidine (PCP)
`
`How ecstasy is taken
`How ecstasy istaken
`MDMA comes in the form of a white, crys-
`MDMA comes in the form of a white, crys-
`talline powder which can be buffered and
`talline powder which can be buffered and
`pressed into pills.10 The usual dose taken by
`pre$ed into pills10 The usual dose taken by
`young people is 1 to 2 mg/kg body weight (125
`youngpeople is 1 to 2 mg/kgbodyvseight (125
`to 180 mg). A 100-mg tablet usually costs
`to 180
`A 100-rng tablet usually costs
`around $20. It may be ingested orally, placed
`around $20. It may be ingested orally placed
`under the tongue, added to juice or a carbon-
`under the tongue, added to juice or a carbon-
`ated beverage, or snorted intranasally.
`ated beverage, or snorted intranasally
`“Candyflipping” is the intentional com-
`"Candyflipping” is the intentional com-
`bination of ecstasy with LSD.
`bination of ecstasy with LSD.
`“Stacking” means taking three or more
`"Stacking" means taking three or more
`tablets at once, or mixing MDMA with LSD,
`tablets at once, or mixing MDMA with LSD,
`alcohol, or marijuana in order to modulate the
`alcohol, or marijuana in order to modulate the
`high. Those who stack may take different
`Those who stack may take different
`drugs at different times throughout an evening
`drugs at different times throughout an evening
`to modify their high: eg, they start with ecsta-
`to
`their
`eg, they start with ecsta-
`sy, add amphetamine or cocaine while coming
`sy add amphetamine or cocaine while coming
`down, and add cannabis, alcohol, GHB, or
`down, and add cannabis, alcohol, GHB, or
`ketamine as the evening continues. Stacking
`ketamine as the evening continues Stacking
`increases the risk of overdose, as the stimulant
`increases the risk of overdose, as the stimulant
`effects of MDMA may mask the sedative
`effects of MDMA may mask the sedative
`effects of alcohol or opiates. Moreover, alco-
`effects of alcohol or opiates Moreover, alco-
`hol use can induce diuresis, further augment-
`hol use can induce diuresis, further augrnent-
`ing the risk of dehydration from the marathon
`ing the risk of dehydration from the marathon
`dancing typical at raves.
`dancing typical at raves
`
`A 100-mg
`A 100-mg
`tablet of
`tablet of
`ecstasty costs
`ecstasty costs
`$20
`$20
`
`How ecstasy works
`How ecstasy works
`MDMA has a half-life of 6 hours, and the time
`MDMA has a half-life of 6 hours, and the time
`to onset of action varies greatly from person to
`to onset of action varies greatly from person to
`person. It works by releasing serotonin and
`person. It works by releasing serotonin and
`dopamine into the brain. This surge of sero-
`dopamine into the brain. This surge of sero-
`tonin creates the feeling of love or ecstasy,
`tonin creates the feeling of love or ecstasy,
`extending to all people with whom the user
`extending to all people with whom the user
`comes into contact. The release of dopamine
`comes into contact. The release of dopamine
`keeps the user from feeling any pain. Thus, a
`keeps the user from feeling any pain. Thus, a
`user may dance for hours on a broken ankle
`user may dance for hours on a broken ankle
`without realizing it.
`without realizing it.
`Wockhardt 1022
`
`The release of neurotransmitters also
`The release of neurotransmitters alm
`decreases body temperature perception, and
`decreases body temperature perception, and
`users of MDMA can overheat without feeling
`users of MDMA can overheat without feeling
`any discomfort (TABLE 1).
`any discomfort (TABLE 1).
`
`The ecstasy ‘rush’
`The ecstasy ‘rush’
`Ingestion of ecstasy is followed by an almost
`Ingestion of ecstasy is follovsed by an almost
`instantaneous “rush,” occurring in approxi-
`instantaneous ”rush,” occurring in approxi-
`mately 30 to 45 seconds if taken on an empty
`mately 30 to 45 seconds if taken on an empty
`stomach. This rush lasts 15 to 30 minutes and
`stomach. This rush lasts 15 to 30 minutes and
`is followed by a gradual descent back to nor-
`is followed by a gradual descent back to nor-
`mal consciousness. Just after the rush, the user
`mal consciousne$. Just after the rush, the user
`experiences a sudden clarity and intensifica-
`experiences a sudden clarity and intensifica-
`tion of perceptions, seeing objects as “brighter
`tion of perceptions, seeing obj ects as ”brighter
`and crisper” and feeling an inner sensation of
`and crisper” and feeling an inner sensation of
`happiness, with people seeming lovable exact-
`happine$, with people seeming lovable exact-
`ly as they are. At this point users usually take
`ly as they are. At this point users usually take
`a booster dose of MDMA to prolong these
`a booster dose of MDMA to prolong these
`feelings. Unfortunately, booster doses increase
`feelings Unfortunately, booster doses increase
`tolerance to the desired effects and an increase
`tolerance to the desired effects and an increase
`in the adverse effects of coming down.
`in the adverse effects of coming down.
`“Bubble bursting” refers to a buildup of
`”Bubble bursting” refers to a
`of
`anxiety, fear, stomach tightness, nausea, or
`anxiety, fear, stomach tightne$, nausea, or
`panic instead of the expected rush.
`panic instead of the expected rush.
`Thirty minutes to 3 hours after the initial
`Thirty minutes to 3 hours after the initial
`“coming on,” or perception of enhanced feel-
`”coming on,” or perception of enhanced feel-
`ing, users experience a “plateau” phase of less-
`ing users experience a ” lateau” phase of le$-
`intense feelings. During the plateau, repetitive
`intense feelings During the plateau, repetitive
`or trance-like movements become extremely
`or trance-like movements become extremely
`pleasurable, leading to long-lasting ecstatic
`pleasurable,
`leading to long-lasting ecstatic
`states of “trance dancing.” Rhabdomyolysis
`states of ”trance dancing” Rhabdomyolysis
`can easily occur during this phase of extended
`can easily occur during this phase of extended
`activity.
`activity
`The “coming down” phase occurs 3 to 6
`The ”coming down” phase occurs 3 to 6
`hours after initial ingestion. During this phase,
`hours after initial ingestion. During this phase,
`feelings of disappointment and other negative
`feelings of disappointment and other negative
`emotions (eg, depression, anxiety) can
`emotions
`(eg, depre$ion,
`anxiety)
`can
`emerge, with sluggishness and residual effects
`emerge, with slugishne$ and residual effects
`lasting up to several days. It may take up to 6
`lasting up to several days It may take up to 6
`to 7 hours to fall asleep after returning to “nor-
`to 7 hours to fall asleep after returning to ”nor-
`mal,” despite extreme exhaustion.
`mal,” despite extreme exhaustion.
`
`Adverse effects of ecstasy
`Adverse effects of ecstasy
`Serious rhabdomyolysis can occur with use of
`Serious rhabdomyolysis can occur with use of
`MDMA and other drugs (TABLE 1). Other side
`MDMA and other drugs (TABLE 1). Other side
`effects of MDMA are listed in TABLE 2.
`effects of MDMA are listed in TAB|.E 2.
`In the short term, coming down is associ-
`In the short term, coming down is associ-
`ated with a relative depletion of serotonin; the
`ated with a relative depletion of serotonin; the
`result is called the “Tuesday blues,” a sluggish
`result is called the ‘Tuesday blues,” a slugish
`feeling lasting several days after ingestion.
`feeling lasting several days after ingestion.
`The long-term effects of MDMA use are
`The long-term effects of MDMA use are
`being studied. Experts suspect that it may
`being studied Experts suspect that it may
`
`544
`
`JUNE 2001
`VOLUME 68 - NUMBER 6
`CLEVELAND CLINIC JOURNAL OFMEDICINE
`CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001
`Downloaded from www.ccjm.org on June 4, 2014. For personal use only. All other uses require permission.
`Downloaded from
`www.ccjm.org
` on June 4, 2014. For personal use only. All other uses require permission.
`
`Wockhardt 1022
`
`

`
`short-circuit the serotonin pathway with
`short-circuit
`the serotonin pathway with
`repeated use over the long term, potentially
`repeated use over the long term, potentially
`causing a shortage of serotonin and subse-
`causing a shortage of serotonin and subse-
`quent depression. At the present time, how-
`quent depresion. At the present time, how-
`ever, this concept is purely speculative.
`ever, this concept is purely speculative.
`
`Management of overdose
`Management of overdose
`MDMA is metabolized in the liver to MDA,
`MDMA is metabolized in the liver to MDA,
`which is then excreted in the urine; thus, typ-
`which is then excreted in the urine; thus, typ-
`ical urine drug tests may only detect MDA.
`ical urine drug tests may only detect MDA.
`Urine toxicology testing picks up certain
`Urine toxicology testing picks up certain
`other drugs that may have been simultaneous-
`other drugs that may have been simultaneous-
`ly ingested, including cannabis, hallucino-
`ly ingested,
`including cannabis, hallucino-
`gens, phencyclidine (PCP), or stimulants.
`gens, phencyclidine (PCP), or stimulants.
`Assessing the serum blood alcohol level can
`A$e$ing the serum blood alcohol level can
`be useful. A monoclonal immunoassay for
`be useful. A monoclonal
`immunoa$ay for
`amphetamine or methamphetamine detects
`amphetamine or methamphetamine detects
`MDMA if the drug was taken in large doses.8
`MDMAifthedrugwastakeninlargedoses3
`Thin-layer chromatography can also detect
`Thin-layer chromatography can also detect
`MDMA metabolites in the urine. Whenever
`MDMA metabolites in the urine. Whenever
`amphetamines are found on immunoassay
`amphetamines are found on immunoa$ay
`screening tests, the results can be confirmed
`screening tests, the results can be confirmed
`by gas chromatography or mass spectrometry.
`by gas chromatography or ma$ spectrometry
`Management of acute heat injury in
`Management of acute heat
`injury in
`MDMA users includes rapid rehydration and
`MDMA users includes rapid rehjdration and
`core cooling. Management of rhabdomyolysis
`core cooling Management of rhabdomyolysis
`involves rehydration, correction of electrolyte
`involves rehjdration, correction of electrolyte
`imbalances, urine alkalinization, and use of
`imbalances, urine alkalinization, and use of
`furosemide as needed. Short-acting benzodi-
`furosemide as needed Short-acting ben2odi-
`azepines can be administered intravenously or
`azepines can be administered intravenously or
`intramuscularly for patients with extreme agi-
`intramuscularly for patients with extreme agi-
`tation, panic reactions, or seizures. Neurologic
`tation,