REVIEW
`
`ELLEN S. ROME, MD, MPH
`Head, Section of Adolescent Medicine,
`Cleveland Clinic
`
`n ABSTRACT
`Illicit drug use by young people has changed in the last
`decade, with the increasing use of “designer” or “club”
`drugs such as ecstasy. Keeping abreast of current trends in
`illicit drug use prepares the primary care clinician to
`recognize the clinical effects of drug use, to manage drug
`emergencies, and to detect addictive behavior. Today’s
`widely used drugs, their street names, their effects, and how
`to manage overdoses are reviewed.
`n KEY POINTS
`Popular “designer” drugs include ecstasy, gamma-
`hydroxybutyrate (GHB), Rohypnol, ketamine, herbal ecstasy
`(ma huang, ephedra), and methamphetamine.
`
`It’s a rave new world: Rave culture
`and illicit drug use in the young
`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 effects of
`these drugs or how to test for them.
`A major trend since the early 1990s has
`been the use of “designer” or “club” drugs such
`as “ecstasy” at raves—all-night dance parties
`with marathon dancing to electronic “techno”
`music. Use of the designer drugs gamma-
`hydroxybutyrate (GHB), Rohypnol, and keta-
`mine, also called “date rape” drugs, is wide-
`spread enough to have prompted Congress to
`adopt the Drug-Induced Rape Prevention and
`Punishment Act of 1996, which increased
`Federal penalties for use of any controlled sub-
`stance to aid in sexual 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 clini-
`cian’s ability to recognize and manage overdos-
`es and to pick up clues of addiction in young
`patients. This article briefly reviews the scope
`of illicit drug use in young people and the most
`popular designer drugs.
`
`Designer drugs are easily obtainable and affordable at
`raves—all-night dance parties with marathon dancing to
`electronic “techno” dance music.
`
`Other substances associated with rave culture include
`“smart drinks” sold for rehydration; these may contain ma
`huang, caffeine, guarana (a caffeine-like stimulant), and
`ginseng.
`
`When questioning teens and young adults about drug use,
`a non-confrontational approach helps. The clinician needs
`to establish confidentiality and to define the limits of that
`confidentiality.
`
`PATIENT INFORMATION
`Date rape drugs: What parents should know, page 551
`
`n THE SCOPE OF DRUG ABUSE
`IN THE YOUNG
`
`Illicit drug use continues to be prevalent
`among young people. Some of the drugs used
`are familiar (alcohol, marijuana) and some are
`newer and perhaps unfamiliar to many of us.1
`The percentage of 8th graders reporting
`illicit drug use doubled from 11.3% in 1991 to
`21.4% in 1995.2 Then, after 1 or 2 years of
`decline in the late 1990s, the use of marijuana,
`amphetamines, tranquilizers, heroin, and alco-
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`ILLICIT DRUG USE
`
`ROME
`
`The rave scene: A closer look
`R
`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
`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
`fields. They first became popular in Great Britain in
`substantially linked economically to fundraising or
`the late 1980s.
`cultural events.
`Alcohol is not sold at many raves, but designer
`In Montreal, this circuit has been estimated to
`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.
`fruit juice mixed with amino acid powders and B
`vitamins to replenish fluids lost during strenuous
`marathon dancing.
`
`SPREADING THE WORD
`Two to three days before a rave, information about
`the location is disseminated via the Internet (eg,
`links accessible from www.dancesafe.org), fliers, or
`word of mouth. Raves are sometimes advertised
`under alluring names, such as “Rave New World” or
`“Save the Rave Forest.”7 Raves attract mainly peo-
`ple 16 to 21 years old, but younger teens and some
`adults also frequent these parties. A single rave in
`Ohio attracted young people from a five-state area.
`Some rave fans go from city to city in search of the
`next best rave.
`
`OTHER TYPES OF RAVES
`“Bush parties” are outdoor parties often with a
`sports focus; alcohol use at these events tends to
`exceed drug use.
`
`ATTEMPTS TO MAKE DRUG USE AT RAVES SAFER
`Drug safety check stations. Because the
`designer drugs sold at raves are not always pure,
`many raves now feature stations where users can
`have the purity of their drugs checked, without the
`risk of being arrested for possession. This is an effort
`to increase the safety of illicit drug use by letting
`users know exactly what they are taking. Many
`local police departments arrest only those individu-
`als caught selling drugs.
`Safe spaces. In Montreal, physicians often go
`to raves to create “safe spaces” for medical triage
`and urgent referral to local emergency rooms. This
`practice is one of damage control rather than pri-
`mary prevention and has been controversial
`among adolescent medicine professionals. 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
`actual drug use.
`
`hol among 8th, 10th, and 12th graders stopped
`declining and leveled off from 1998 to 1999,
`according to the National Institute on Drug
`Abuse’s 1999 Monitoring the Future study.3
`
`Alcohol
`Alcohol is the most widely used drug among
`young people, with four out of every five stu-
`dents having consumed alcohol by the end of
`high school, and 52% by the 8th grade.3
`Almost two thirds of 12th graders and one
`fourth of 8th graders reported having been
`drunk at least once.3 Binge drinking rates
`have leveled off in the past few years, just as
`designer drugs started gaining in popularity.
`Alcohol-drug combinations. A popular
`trend is to combine alcohol with over-the-
`
`counter drugs. One example is a “roboshot”—
`1 to 2 ounces of Robitussin DM chugged with
`a 12-ounce beer. This allegedly produces a
`“buzz” equivalent to a six-pack of beer, with-
`out any hangover.
`
`Marijuana
`Marijuana is the 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, and 1.4%
`of 8th graders, 3.8% of 10th graders, and 6.0%
`of 12th graders 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 steadily declined, with 10%
`of 8th graders, 7% of 10th graders, and 6% of
`12th graders reporting use at least once during
`1999. The data for the year 2000 show
`inhalant use continues to be more prevalent
`in younger teens.4
`Inhalants are readily accessible. A wide
`range of common household products are
`used, including glue, solvents, butane, gaso-
`line, and aerosols.
`
`Anabolic steroids
`Among young people, use of anabolic steroids
`is more common in boys than in girls. Steroid
`use increased in 1999, with 2.5% of 8th
`graders and 2.8% of 10th graders using
`steroids.3 These rates almost doubled com-
`pared with 1998 rates of 1.6% and 1.9%,
`respectively, and fewer 12th graders consid-
`ered steroids as risky as they did the previous
`year. The 2000 Monitoring the Future study4
`showed that between 1999 and 2000 the use
`of anabolic steroids increased among 10th
`graders.
`
`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 designer drugs
`currently include:
`• Ecstasy, the common name for 3-4 meth-
`ylenedioxymethamphetamine (MDMA),
`also called “Adam” and “XTC”
`• The date rape drugs GHB, flunitrazepam
`(known mainly by its brand name,
`Rohypnol), and ketamine
`• Herbal ecstasy, another name for ma
`huang or ephedra
`• Methamphetamine.
`The makeup of these designer drugs, as
`well as their desired effects, their short-term
`and long-term adverse effects, and how to
`manage overdose are discussed later in this
`article.
`Ecstasy. In a random survey of illicit drug
`use in undergraduates attending Tulane
`University in 1990, use of ecstasy was report-
`ed by 24% of those surveyed.5 In 1996, 5% of
`US 16-year-olds reported ecstasy use.6
`According to the 1999 Monitoring the Future
`Study,3 4.4% of 10th graders and 5.6% of 12th
`
`graders reported using ecstasy in the past year.
`The 2000 Monitoring the Future Study
`showed that the use of ecstasy by all three
`groups increased.4
`GHB is a date rape drug either intention-
`ally used or surreptitiously administered to
`incapacitate a victim, preventing her or him
`from resisting sexual assault. As with other
`date rape drugs, its use is not confined to date
`rape situations.
`No data on the prevalence of its use are
`available as of this writing. Nevertheless,
`the problem of GHB, Rohypnol, and keta-
`mine use received sufficient national atten-
`tion to prompt Congress to pass a law
`increasing penalties for using drugs in sexual
`assault.
`Rohypnol is an anti-seizure drug avail-
`able in Europe but not in the United States.
`Rohypnol use showed a small decline in
`1999, with 0.5% of 8th graders and 1.0% of
`10th and 12th graders reporting use.3
`Rohypnol may be lethal when combined
`with alcohol.3,7
`Ketamine is a rapid-acting general anes-
`thetic used as an alternative to cocaine and
`usually snorted. No data on the prevalence
`of ketamine use are available as of this writ-
`ing.
`
`n ECSTASY
`
`Ecstasy (MDMA, XTC, X, E, Adam) is a syn-
`thetic, psychoactive, hallucinogenic drug,
`first synthesized in Germany by Merck in
`1914 to facilitate communication during psy-
`chotherapy.8 It is an amphetamine analogue
`and a selective serotonergic neurotoxin.
`Experimentation in humans has been traced
`back only to the early 1970s.9 Its use was
`criminalized in the United States in 1985,9 by
`which time it had jumped from the psychia-
`trist’s couch to the dance floor.
`Much of what is sold as ecstasy is not pure
`MDMA, but may be any combination of 3,4-
`methylenedioxyamphetamine (MDA, the
`love pill, the love drug, or speed for lovers),
`N-ethyl-methylendioxyamphetamine (MDE,
`Eve), lysergic acid diethylamide (LSD),
`amphetamine, caffeine, heroin, or lactose.
`MDE produces effects similar to those of
`MDMA but turns the subject inwards.
`
`GHB, Rohypnol,
`and ketamine
`are the date
`rape drugs
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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)
`
`A 100-mg
`tablet of
`ecstasty costs
`$20
`
`How ecstasy is taken
`MDMA comes in the form of a white, crys-
`talline powder which can be buffered and
`pressed into pills.10 The usual dose taken by
`young people is 1 to 2 mg/kg body weight (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 intranasally.
`“Candyflipping” is the intentional com-
`bination of ecstasy with LSD.
`“Stacking” means taking three or more
`tablets at once, or mixing MDMA with LSD,
`alcohol, or marijuana in order to modulate the
`high. Those who stack may take different
`drugs at different times throughout an evening
`to modify their high: eg, they start with ecsta-
`sy, add amphetamine or cocaine while coming
`down, and add cannabis, alcohol, GHB, or
`ketamine as the evening continues. Stacking
`increases the risk of overdose, as the stimulant
`effects of MDMA may mask the sedative
`effects of alcohol or opiates. Moreover, alco-
`hol use can induce diuresis, further augment-
`ing the risk of dehydration from the marathon
`dancing typical at raves.
`
`How ecstasy works
`MDMA has a half-life of 6 hours, and the time
`to onset of action varies greatly from person to
`person. It works by releasing serotonin and
`dopamine into the brain. This surge of sero-
`tonin creates the feeling of love or ecstasy,
`extending to all people with whom the user
`comes into contact. The release of dopamine
`keeps the user from feeling any pain. Thus, a
`user may dance for hours on a broken ankle
`without realizing it.
`
`The release of neurotransmitters also
`decreases body temperature perception, and
`users of MDMA can overheat without feeling
`any discomfort (TABLE 1).
`
`The ecstasy ‘rush’
`Ingestion of ecstasy is followed by an almost
`instantaneous “rush,” occurring in approxi-
`mately 30 to 45 seconds if taken on an empty
`stomach. This rush lasts 15 to 30 minutes and
`is followed by a gradual descent back to nor-
`mal consciousness. Just after the rush, the user
`experiences a sudden clarity and intensifica-
`tion of perceptions, seeing objects as “brighter
`and crisper” and feeling an inner sensation of
`happiness, with people seeming lovable exact-
`ly as they are. At this point users usually take
`a booster dose of MDMA to prolong these
`feelings. Unfortunately, booster doses increase
`tolerance to the desired effects and an increase
`in the adverse effects of coming down.
`“Bubble bursting” refers to a buildup of
`anxiety, fear, stomach tightness, nausea, or
`panic instead of the expected rush.
`Thirty minutes to 3 hours after the initial
`“coming on,” or perception of enhanced feel-
`ing, users experience a “plateau” phase of less-
`intense feelings. During the plateau, repetitive
`or trance-like movements become extremely
`pleasurable, leading to long-lasting ecstatic
`states of “trance dancing.” Rhabdomyolysis
`can easily occur during this phase of extended
`activity.
`The “coming down” phase occurs 3 to 6
`hours after initial ingestion. During this phase,
`feelings of disappointment and other negative
`emotions (eg, depression, anxiety) can
`emerge, with sluggishness and residual effects
`lasting up to several days. It may take up to 6
`to 7 hours to fall asleep after returning to “nor-
`mal,” despite extreme exhaustion.
`
`Adverse effects of ecstasy
`Serious rhabdomyolysis can occur with use of
`MDMA and other drugs (TABLE 1). Other side
`effects of MDMA are listed in TABLE 2.
`In the short term, coming down is associ-
`ated with a relative depletion of serotonin; the
`result is called the “Tuesday blues,” a sluggish
`feeling lasting several days after ingestion.
`The long-term effects of MDMA use are
`being studied. Experts suspect that it may
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`
`short-circuit the serotonin pathway with
`repeated use over the long term, potentially
`causing a shortage of serotonin and subse-
`quent depression. At the present time, how-
`ever, this concept is purely speculative.
`
`Management of overdose
`MDMA is metabolized in the liver to MDA,
`which is then excreted in the urine; thus, typ-
`ical urine drug tests may only detect MDA.
`Urine toxicology testing picks up certain
`other drugs that may have been simultaneous-
`ly ingested, including cannabis, hallucino-
`gens, phencyclidine (PCP), or stimulants.
`Assessing the serum blood alcohol level can
`be useful. A monoclonal immunoassay for
`amphetamine or methamphetamine detects
`MDMA if the drug was taken in large doses.8
`Thin-layer chromatography can also detect
`MDMA metabolites in the urine. Whenever
`amphetamines are found on immunoassay
`screening tests, the results can be confirmed
`by gas chromatography or mass spectrometry.
`Management of acute heat injury in
`MDMA users includes rapid rehydration and
`core cooling. Management of rhabdomyolysis
`involves rehydration, correction of electrolyte
`imbalances, urine alkalinization, and use of
`furosemide as needed. Short-acting benzodi-
`azepines can be administered intravenously or
`intramuscularly for patients with extreme agi-
`tation, panic reactions, or seizures. Neurologic
`assessment and vital signs should be checked
`frequently. Dantrolene may be useful in coun-
`teracting MDMA-associated muscle spasms;
`beta-blockers, calcium channel blockers, or
`procainamide may be required to treat cardiac
`arrhythmias. If a patient seems likely to injure
`himself or others, a quiet, dark setting with
`judicious use of benzodiazepines is imperative.
`
`n GAMMA-HYDROXYBUTYRATE (GHB)
`
`T A B L E 2
`Adverse effects of MDMA
`(ecstasy) use
`
`Addiction (to concurrently used substances,
`eg, amphetamines, heroin, cocaine)
`Arrhythmias
`Coagulopathy (disseminated intravascular)
`Confusion
`Coma
`Death
`Dehydration
`Electrolyte imbalances
`Fatigue
`Heat injury (fatal, sometimes referred to as
`“Saturday night fever”)
`Hepatic toxicity
`Jaw-clenching
`Muscle spasms
`Pregnancy (unwanted)
`Rape
`Renal failure (acute)
`Tachycardia
`Teratogenicity
`
`GHB‘s effects
`vary greatly
`from person
`to person
`
`tectable when mixed with beverages.
`Developed as an adjunct to anesthesia,
`GHB was believed in the 1970s to have clini-
`cal value in the treatment of narcolepsy. In the
`1980s, it was used by weight lifters to increase
`the metabolic rate. In the 1990s, “blue nitro,”
`a GHB precursor, was used as a weight-loss
`preparation, while Serenity, another GHB pre-
`cursor, was used by body builders. GHB’s pur-
`ported medicinal value was eventually over-
`shadowed by its unpredictability: a given dose
`could completely anesthetize one patient and
`have no effect on another.
`
`GHB—also known as liquid ecstasy, easy lay,
`grievous bodily harm, cherry meth, soap,
`growth hormone booster, gook, liquid X, liq-
`uid G, and liquid E—is a precursor of the neu-
`rotransmitter gamma aminobutyric acid
`(GABA) that acts on the dopaminergic sys-
`tem. GHB is usually sold as a salty, clear liquid
`in small bottles and is taken by the capful. It
`is also available in capsule form. GHB is unde-
`
`How GHB works
`GHB’s central nervous system effects include
`mediation of sleep cycles, temperature regula-
`tion, cerebral glucose metabolism and blood
`flow, memory, and emotional control.11 The
`onset of action is within 15 to 60 minutes, and
`effects last from 1 to 3 hours. The half-life is
`27 minutes, with elimination by expired
`breath as carbon dioxide.
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`ILLICIT DRUG USE
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`ROME
`
`Desired effects of GHB
`Young people take GHB to experience
`euphoria, disinhibition, and sexual 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 mydriasis or miosis, another indication
`of the inconsistent response from person to
`person. In severe cases, the classic triad of
`symptoms includes coma, bradycardia, and
`myoclonus. Hallucinations can also occur.
`As the patient starts to recover, “emer-
`gence phenomena” can occur, characterized
`by myoclonic jerking motions, transient con-
`fusion, and combativeness, followed by rapid
`recovery of consciousness.11,12
`Other effects include delusions, depres-
`sion, altered mental status, apnea, hypoten-
`sion, nausea, vomiting, vertigo, respiratory
`distress, transient metabolic acidosis, loss of
`airway reflexes, ataxia, nystagmus, aggressive
`behavior, somnolence, anterograde amnesia,
`and coma.
`Adverse effects are potentiated by alco-
`hol, ketamine, benzodiazepines, major tran-
`quilizers, opiates, anticonvulsants, and over-
`the-counter cold and sleep medicines. All of
`the above can exacerbate respiratory depres-
`sion. Use with methamphetamine increases
`the risk of seizure.
`
`Management of GHB overdose
`Management of GHB overdose consists 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 severe cases, rapid intubation
`with succinylcholine paralysis may be
`required for advanced airway protection.13 If
`abuse of multiple drugs is suspected, orogas-
`tric lavage and administration of activated
`charcoal with sorbitol is recommended. If the
`patient is still intoxicated at 6 hours after
`ingestion, hospital admission is warranted.
`Otherwise, if alert, responsive, and normal
`on physical examination 6 hours after inges-
`tion, the patient can be discharged from the
`emergency room.
`
`n KETAMINE
`
`Ketamine (special K, vitamin K, new ecstasy,
`ketalar, ketaject, psychedelic heroin, and
`super K) is a shorter-acting, less potent alter-
`native to PCP. It is used by veterinarians as an
`anesthetic, is available in both liquid and
`powder forms and has a bitter taste. The liquid
`form is usually ingested orally or intravenous-
`ly. In white powder form it is either snorted by
`itself or smoked with marijuana 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 alco-
`hol, barbiturates, opiates, GHB, and valium. If
`taken intramuscularly, effects occur within 2
`minutes. If taken orally, effects occur within
`15 to 20 minutes, or sooner on an empty
`stomach. If taken intranasally, the dose is
`repeated every 5 minutes until the desired
`effects are achieved.
`
`Desired effects of ketamine
`Effects last 2 to 3 hours. Low doses lead to feel-
`ings of relaxation, and high doses bring on a
`sensation of a near-death experience (known
`as the “K-hole”) and loss of sense of time and
`identity. “K-land” refers to hallucinations and
`visual distortions. The user feels no pain, a
`state that can lead to unintentional injuries
`the user may not be aware of until he or she
`comes down.
`
`Adverse effects of ketamine
`Short-term physical effects include tachycar-
`dia, hypertension, impaired motor function,
`respiratory depression, bronchodilation, pap-
`illary dilation, and nausea. Short-term psy-
`chologic effects include dissociation, depres-
`sion, recurrent flashbacks, delirium, and
`amnesia.
`Long-term adverse effects are currently
`unknown, but brain damage has been
`observed in animal studies. Persons who use
`ketamine while taking antibiotics (eg,
`ofloxacin), anticholinergics, antipsychotics,
`bupropion (Wellbutrin and Zyban), caffeine,
`or GHB increase their risk of seizure. Under
`the drug’s 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 unpleasant mental and visual side
`effects of ketamine.14 The clinician should
`watch for oversedation, protecting the airways
`as necessary.
`
`n ROHYPNOL
`
`Rohypnol, (the date rape drug, ruffies, roofies,
`rouches, the forget pill) is licensed in Europe,
`Asia, and Latin America as an anti-seizure
`drug. It is a benzodiazepine 10 times more
`potent than diazepam (Valium). It is sold as
`individually wrapped tablets that are colorless,
`odorless, and tasteless when mixed in bever-
`ages.
`
`Desired effects of rohypnol
`Desired effects include disinhibition, amnesia,
`and muscle relaxation, but individual effects
`vary.
`
`Adverse effects of rohypnol
`Adverse effects include sedation, respiratory
`depression, impaired motor coordination,
`confusion, memory loss, hallucinations, and
`potential overdose when combined with alco-
`hol. Paradoxically, it may cause aggressiveness
`in some cases.
`
`Management of rohypnol overdose
`Rohypnol is not detectable with routine urine
`toxicology screening. Airway protection and
`blood pressure control may be warranted.
`Midazolam (Versed), used as a sedative before
`endoscopy, can be used in severe cases to
`reverse benzodiazepine effects, but longer
`observation would be indicated.
`
`n HERBAL ECSTASY
`
`Herbal ecstasy (ma huang, ephedra) is used as
`a stimulant or a weight-loss agent and is avail-
`able at many health food stores and by mail
`order from sources advertised in drug culture
`magazines. It is an ingredient in some Chinese
`herbal medications and in nutritional supple-
`ments such as Metabolift and Metabolife 356.
`A 300-mg dose of ephedra is equivalent to 30
`mg of ephedrine. Ephedrine is found in many
`over-the-counter cold preparations. Neither
`
`ephedra nor its extracted form ephedrine are
`regulated by the US Food and Drug
`Administration.
`
`Desired effects of herbal ecstasy
`The effects of herbal ecstasy last 3 to 4 hours
`when taken orally. Three tablets taken
`together have an effect similar to ampheta-
`mines or a large dose of caffeine.
`
`Adverse effects of herbal ecstasy
`Adverse effects include tachycardia, hyper-
`tension, stroke, seizure, myocardial infarction,
`and death. The doses needed to produce these
`effects are not known. These substances are
`not regulated by the Food and Drug
`Administration, and it is hard to know exact-
`ly how much of any given substance a product
`contains.
`
`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 people with cardiac problems or high blood
`pressure. Hypertension in persons who have
`overdosed on herbal ecstasy may respond to
`the use of benzodiazepines to decrease anxiety.
`Nitroprusside should be used in hypertensive
`crisis.
`
`n METHAMPHETAMINE
`
`Methamphetamine (ice, crystal meth, speed,
`tweak, crank, glass, or tina) is a highly addic-
`tive stimulant that causes the release of large
`amounts of dopamine, enhancing mood and
`body movement. It is sold either as a white
`powder that is taken orally, intranasally, intra-
`venously, or rectally, or as a clear, crystal-
`shaped “rock” that is heated and smoked like
`crack cocaine. The smoked form is called ice,
`crystal, and glass.
`
`Desired effects of methamphetamine
`Smoking and intravenous use give a rush
`described as an intense, very pleasurable sen-
`sation that lasts a few minutes. Intranasal and
`oral use do not produce this rush, but rather a
`“high.” Effects occur within 3 to 5 minutes
`with intranasal use and within 15 to 20 min-
`
`Metham-
`phetamine
`is a highly
`addictive
`stimulant
`
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`
`ILLICIT DRUG USE
`
`ROME
`
`utes with oral use, and can last up to 24 hours.
`
`Adverse effects of methamphetamine
`Adverse effects of methamphetamine use
`include a wide variety of physical and psycho-
`logical effects: eg, wakefulness, increased phys-
`ical activity (a hyperalert state, restlessness),
`decreased appetite, headache, mydriasis, sen-
`sation of hair “standing on end,” vasoconstric-
`tion of extremities, dry mouth, hyperreflexia,
`tremors, tachycardia, hypertension, palpita-
`tions, cardiac arrhythmias, cardiomyopathy,
`stroke, hyperthermia, seizures, euphoria, irri-
`tability, insomnia, anxiety, hallucinations,
`paranoia, psychosis, and death.
`Methamphetamine may cause degenera-
`tion of neurons containing the neurotrans-
`mitter dopamine, with damage of these neu-
`rons known to be the underlying cause of the
`motor disturbances seen in Parkinson dis-
`ease.
`
`Management of methamphetamine overdose
`Effects of methamphetamine tend to last 5 to
`10 hours. The drug is metabolized to amphet-
`amine. Urine toxicology screening may pick
`up both methamphetamine and ampheta-
`mine. Gas chromatography and mass spec-
`trometry can differentiate methamphetamine
`from amphetamine.
`In case of overdose, haloperidol can be
`used to control agitation, and benzodiazepines
`can be used to control seizures. Hypertension
`can be managed with intravenous beta-block-
`ers. Cardiac monitoring and precautions to
`prevent seizure are usually indicated. Some
`patients may require airway protection.
`
`n OTHER CLUB DRUGS
`
`GHB precursors
`A commonly found GHB precursor is gamma-
`butyrolactone (GBL), also known as blue
`nitro, gamma-G, 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 and a longer duration. Adverse effects
`include respiratory depression and cardiac dys-
`rhythmia. It is metabolized in the liver into
`GHB but can also be made into GHB using
`home kits. Other precursors to GHB include
`
`tetramethylene glycol and 2(3H)-furanone di-
`hydro.
`
`Smart drinks
`In addition to alcohol, marijuana, cocaine,
`and amphetamines, other substances associat-
`ed with the rave subculture are stimulants
`called “smart drinks” (see “The rave scene: a
`closer look, page 542), also called “power
`drinks,”which are used to prevent dehydra-
`tion. They are sold at both raves and nutrition
`stores and come in bottles or cans or as pow-
`ders or capsules. They may contain ma huang,
`caffeine, guarana (a stimulant similar to caf-
`feine), ginseng, amino acids, taurine, sugars,
`tryptophan, and high doses of B and C vita-
`mins.
`
`Go-go drinks
`Go-go drinks, similar to power drinks, are also
`sold at raves and contain ginseng, yohimbine,
`and guarana. They are marketed as “Viagra for
`women.” They are used to boost energy levels,
`to increase stamina, to quench thirst, and to
`enhance concentration. Most contain stimu-
`lants. Taken in excess they can cause nausea,
`loss of appetite, insomnia, tachycardia, visual
`and sensory impairment, and bladder and uri-
`nary tract discomfort. People with heart or
`kidney disease, hypertension, hypotension,
`asthma, and diabetes mellitus should not use
`them.
`
`n MANAGING DESIGNER DRUG ABUSE:
`ADDITIONAL CONSIDERATIONS
`
`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 screening does not detect LSD,
`inhalants, alcohol, benzodiazepines such as
`alprazolam (Xanax) and lorazepam (Ativan),
`and methylphenidate (Ritalin). Thin-layer
`chromatography can be requested, specifying
`suspected drugs based on the history and phys-
`ical examination.
`The patient should be placed in a warm,
`dark room. When possible, the patient and
`friends should be questioned as to what drugs
`were ingested and in what form.
`In crisis situations, stabilize the patient
`
`Stimulant-
`containing
`drinks are used
`to prevent
`dehydration
`
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`T A B L E 3
`Ocular effects
`of commonly abused drugs
`
`T A B L E 4
`Cardiovascular effects
`of commonly abused drugs
`
`Conjunctival injection
`Lysergic acid diethylamide (LSD)
`Marijuana
`Miosis
`Alcohol
`Barbiturates
`Benzodiazepines
`Opiates
`Phencyclidine (PCP)
`Mydriasis
`Alcohol or opiate withdrawal
`Amphetamines/stimulants
`Cocaine
`Glutethimide
`Jimson weed
`LSD
`Nystagmus
`Alcohol
`Barbiturates
`Benzodiazepines
`Inhalants
`PCP
`Tearing (excessive lacrimation)
`Inhalants
`LSD
`Opiate withdrawal
`
`Arrhythmia
`Amphetamines/stimulants
`Cocaine
`Inhalants
`Opiates
`Phencyclidine (PCP)
`Hypertension
`Amphetamines/stimulants
`Cocaine
`Lysergic acid diethylamide (LSD)
`Marijuana
`PCP
`Withdrawal from alcohol, barbiturates,
`benzodiazepines
`Hypotension
`Barbiturates
`Marijuana (orthostatic hypotension)
`Opiates
`Tachycardia
`Amphetamines/stimulants
`Cocaine
`LSD
`Marijuana
`PCP
`Withdrawal from alcohol, barbiturates,
`benzodiazepines
`
`while getting as much history as possible from
`both patient and accompanying peers. Fear
`and concern for a friend may get them to
`s