What you need to know about club drugs.
"In supposedly drug-free zones, 40% of high school seniors say it's relatively easy to get drugs and about 5% of eighth graders say they have used Ecstasy once. About 15% of high school seniors say they have. It's definitely an issue," said Dr. Stephens of the Naval Hospital at Sigonella, Italy.
Once known for warehouse-size venues, today's raves are smaller, themed, underground parties featuring electronica music, laser light shows, and an abundance of drugs. Dr. Stephens outlined the most popular:
Better known as Ecstasy, Methylenedioxymethamphetamine (MDMA) was initially used as an appetite suppressant, then as a psychiatric drug, before becoming the star of the rave scene. "It's a stimulant and a hallucinogen, so it's kind of an intriguing chemical product because it crosses traditional boundaries in terms of effect," said Dr. Stephens.
MDMA acts on dopaminergic centers in the brain producing feeling-related changes and it also produces more amphetamine-like stimulatory changes. Users are seeking a euphoric, hypermotor state. Often ravegoers will wear a surgical mask with vapor rub dabbed on the inside because they believe it heightens the sensory experience.
Street names for MDMA include X, Adam, XTC, love drug, clarity, 007, and others.
Patients who present to the emergency department (ED) on MDMA appear wired, with psychomotor agitation and sometimes hallucinations, making it hard to pinpoint. Look for hypertension, tachycardia, changes in mental status, and most importantly changes in core temperature. "Some of these folks have problems with malignant hyperthermic state," said Dr. Stephens.
A urine test can be used to confirm diagnosis. Care comes down to managing the patient's ABCs (airway, breathing, and circulation) and keeping the patient quiet.
MDMA is a schedule I drug. Its use accounts for 5,000-6,000 ED episodes yearly, according to the federal Drug Abuse Warning Network (DAWN), a federal effort which allows physicians to report different toxicities to a national database.
Developed to replace phencyclidine (PCP) as a dissociative anesthetic, ketamine is used most commonly in veterinary medicine. Most ketamine used at raves is diverted from veterinary sources, said Dr. Stephens. Ketamine is available as a clear liquid or a white powder.
Ketamine users are trying to get to "k-land" and avoid going to "k-hole." K-land refers to the dissociative experience that accompanies ketamine use. "Folks will tell you that they can see a sound or hear a color in this bizarre synesthetic state," he said.
K-hole refers to the frightening, out-of-body experience associated with ketamine overdose. Large doses can produce vomiting and convulsions and may lead to oxygen starvation to the brain and muscles. Street names for ketamine include cat valium, special k, jet, and others.
The effects of a ketamine "high" are short-lived, usually lasting an hour, but sometimes 4-6 hours. Ketamine users who present to the ED exhibit increased blood pressure and heart rate. Ketamine over-dose is associated with severe dissociation, vomiting, restlessness, and tiredness. Ketamine is not detectable on a routine urine screen.
Emergency treatment of patients with ketamine toxicity is primarily supportive, said Dr. Stephens. Maintain the ABCs and fluid status.
Ketamine is a schedule III drug.
Flunitrazepam (Rohypnol) is 10 times more potent than Valium. Today it is manufactured as 1-mg tablets that are legally available in Europe, Mexico, and Colombia for the treatment of severe sleep disorders. It is not manufactured or approved in the United States. Historically it has come over the borders from Mexico.
Until 1999 it was colorless but a colorimetric compound is now added that turns the drug blue when added to a liquid--making it obvious that a drink has been tampered with. Flunitrazepam has earned a reputation as a date-rape drug. Use has fallen in part due to the color change and in part due to the Drug-Induced Rape Prevention and Punishment Act of 1996, which made it punishable to commit a violent crime using a controlled substance such as flunitrazepam.
This benzodiazepine begins to work in a short period of time, producing muscle relaxation, sleepiness, mental and physical paralysis, and anterograde amnesia that is especially pronounced when combined with alcohol. In short, it's perfect for sexual predators.
Street names for flunitrazepam include roofies, roapies, la roacha, roach-2, Mexican valium, and others.
Flunitrazepam can be identified in a urine sample up to 72 hours after ingestion. "If there is concern about assault, you need to send off for the 7-amino metabolite of flunitrazepam for forensic evidence to hold up," said Dr. Stephens. Care for patients is primarily supportive.
Flunitrazepam is currently classified as schedule IV, but the U.S. Drug Enforcement Administration is considering reclassifying it as schedule I.
The rise in popularity of [gamma]-hydroxybutyrate (GHB) is another reason why flunitrazepam use has fallen.
GHB first garnered use among body builders, who used the drug's euphoric effects to help with marathon weightlifting sessions. GHB was originally marketed as a compound that increased growth hormone release. It can be a clear, odorless liquid or a white powder that is easily slipped into drinks. It has since found a niche in the club scene as a predatory drug. The Food and Drug Administration approved GHB (Xyrem) for the treatment of narcolepsy last year.
GHB is a quick-acting sedative that can produce coma at higher doses. It's often mixed with alcohol, which increases the sedative effect. Street names for GHB include liquid X, Georgia homeboy, verve, grievous bodily harm, and others.
It is difficult to detect in someone's system. A standard urine drug screen does not test for GHB. The best chance of identifying it is to request a specific gas chromatograph analysis.
A patient who is toxic with GHB presents to the ED completely obtunded. The typical approach is to maintain ABCs, run a routine urinalysis, and check some major serochemistries.
The Hillory J. Farias and Samantha Reid Date-Rape Drug Prohibition Act of 2000 reclassified GBH as a schedule I substance. While GHB falls under the controlled substances act, it is still easy to obtain. Two cousins--[gamma]-butyrolactone and 1,4-butanediol--are easily obtained on the Internet and converted to GHB with a little bathtub chemistry, and use of abundant online recipes.
Have you seen club-drug users in your practice?
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For more information, go to http://dawninfo.samhsa.gov or visit the club drug Web page of the National Institute on Drug Abuse at www.clubdrugs.gov.
BY KERRI WACHTER
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|Title Annotation:||Addiction Psychiatry|
|Publication:||Clinical Psychiatry News|
|Date:||Feb 1, 2004|
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