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REVIEW ELLEN S. ROME, MD, MPH Head, Section of Adolescent Medicine, Cleveland Clinic It’s a rave new world: Rave culture and illicit drug use in the young s A B S T R AC T N drugs are popular among young people dangerous illicit EW AND POTENTIALLY Illicit drug use by young people has changed in the last today. Relatively little is known about the decade, with the increasing use of “designer” or “club” short-term and long-term adverse effects of drugs such as ecstasy. Keeping abreast of current trends in these drugs or how to test for them. illicit drug use prepares the primary care clinician to A major trend since the early 1990s has recognize the clinical effects of drug use, to manage drug been the use of “designer” or “club” drugs such as “ecstasy” at raves—all-night dance parties emergencies, and to detect addictive behavior. Today’s with marathon dancing to electronic “techno” widely used drugs, their street names, their effects, and how music. Use of the designer drugs gamma- to manage overdoses are reviewed. hydroxybutyrate (GHB), Rohypnol, and keta- mine, also called “date rape” drugs, is wide- s KEY POINTS spread enough to have prompted Congress to adopt the Drug-Induced Rape Prevention and Popular “designer” drugs include ecstasy, gamma- Punishment Act of 1996, which increased hydroxybutyrate (GHB), Rohypnol, ketamine, herbal ecstasy Federal penalties for use of any controlled sub- (ma huang, ephedra), and methamphetamine. stance to aid in sexual assault (see “Date rape drugs: What parents should know,” page Designer drugs are easily obtainable and affordable at 551). raves—all-night dance parties with marathon dancing to Drug abuse leads to short-term and long- electronic “techno” dance music. term health problems. Keeping abreast of trends in illicit drug use enhances the clini- Other substances associated with rave culture include cian’s ability to recognize and manage overdos- “smart drinks” sold for rehydration; these may contain ma es and to pick up clues of addiction in young huang, caffeine, guarana (a caffeine-like stimulant), and patients. This article briefly reviews the scope ginseng. of illicit drug use in young people and the most popular designer drugs. When questioning teens and young adults about drug use, s THE SCOPE OF DRUG ABUSE a non-confrontational approach helps. The clinician needs IN THE YOUNG to establish confidentiality and to define the limits of that confidentiality. 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 PATIENT INFORMATION decline in the late 1990s, the use of marijuana, Date rape drugs: What parents should know, page 551 amphetamines, tranquilizers, heroin, and alco- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 541 ILLICIT DRUG USE ROME The rave scene: A closer look R AVES ARE PARTIES with loud, electronic “tech- no-rock” music, laser light shows, and all- “Circuit parties” are weekend-long parties or 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 ATTEMPTS TO MAKE DRUG USE AT RAVES SAFER marathon dancing. Drug safety check stations. Because the designer drugs sold at raves are not always pure, SPREADING THE WORD many raves now feature stations where users can Two to three days before a rave, information about have the purity of their drugs checked, without the the location is disseminated via the Internet (eg, risk of being arrested for possession. This is an effort links accessible from www.dancesafe.org), fliers, or to increase the safety of illicit drug use by letting word of mouth. Raves are sometimes advertised users know exactly what they are taking. Many under alluring names, such as “Rave New World” or local police departments arrest only those individu- “Save the Rave Forest.”7 Raves attract mainly peo- als caught selling drugs. ple 16 to 21 years old, but younger teens and some Safe spaces. In Montreal, physicians often go adults also frequent these parties. A single rave in to raves to create “safe spaces” for medical triage Ohio attracted young people from a five-state area. and urgent referral to local emergency rooms. This Some rave fans go from city to city in search of the practice is one of damage control rather than pri- next best rave. mary prevention and has been controversial among adolescent medicine professionals. On one OTHER TYPES OF RAVES hand, this practice has prevented deaths from “Bush parties” are outdoor parties often with a overdose and has provided a source of education; sports focus; alcohol use at these events tends to but on the other hand, it does little to decrease exceed drug use. actual drug use. hol among 8th, 10th, and 12th graders stopped counter drugs. One example is a “roboshot”— declining and leveled off from 1998 to 1999, 1 to 2 ounces of Robitussin DM chugged with according to the National Institute on Drug a 12-ounce beer. This allegedly produces a Abuse’s 1999 Monitoring the Future study.3 “buzz” equivalent to a six-pack of beer, with- out any hangover. Alcohol Alcohol is the most widely used drug among Marijuana young people, with four out of every five stu- Marijuana is the second most widely used drug dents having consumed alcohol by the end of among young people: 17% of 8th graders, 32% high school, and 52% by the 8th grade.3 of 10th graders, and 38% of 12th graders Almost two thirds of 12th graders and one reported having used it at least once, and 1.4% fourth of 8th graders reported having been of 8th graders, 3.8% of 10th graders, and 6.0% drunk at least once.3 Binge drinking rates of 12th graders reported daily use.3 have leveled off in the past few years, just as designer drugs started gaining in popularity. Inhalants Alcohol-drug combinations. A popular For the past 5 years, the use of inhalants by trend is to combine alcohol with over-the- students surveyed in the Monitoring the 542 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 Future Study has steadily declined, with 10% graders reported using ecstasy in the past year. of 8th graders, 7% of 10th graders, and 6% of The 2000 Monitoring the Future Study 12th graders reporting use at least once during showed that the use of ecstasy by all three 1999. The data for the year 2000 show groups increased.4 inhalant use continues to be more prevalent GHB is a date rape drug either intention- in younger teens.4 ally used or surreptitiously administered to Inhalants are readily accessible. A wide incapacitate a victim, preventing her or him range of common household products are from resisting sexual assault. As with other used, including glue, solvents, butane, gaso- date rape drugs, its use is not confined to date line, and aerosols. rape situations. No data on the prevalence of its use are Anabolic steroids available as of this writing. Nevertheless, Among young people, use of anabolic steroids the problem of GHB, Rohypnol, and keta- is more common in boys than in girls. Steroid mine use received sufficient national atten- use increased in 1999, with 2.5% of 8th tion to prompt Congress to pass a law graders and 2.8% of 10th graders using increasing penalties for using drugs in sexual steroids.3 These rates almost doubled com- assault. pared with 1998 rates of 1.6% and 1.9%, Rohypnol is an anti-seizure drug avail- respectively, and fewer 12th graders consid- able in Europe but not in the United States. ered steroids as risky as they did the previous Rohypnol use showed a small decline in year. The 2000 Monitoring the Future study4 1999, with 0.5% of 8th graders and 1.0% of showed that between 1999 and 2000 the use 10th and 12th graders reporting use. 3 of anabolic steroids increased among 10th Rohypnol may be lethal when combined graders. with alcohol.3,7 Ketamine is a rapid-acting general anes- Designer drugs thetic used as an alternative to cocaine and A number of drugs are used by teens and usually snorted. No data on the prevalence young adults who frequent raves, bars, and of ketamine use are available as of this writ- GHB, Rohypnol, nightclubs, where they are relatively easy to ing. and ketamine obtain and affordable. Popular designer drugs currently include: s ECSTASY are the date • Ecstasy, the common name for 3-4 meth- ylenedioxymethamphetamine (MDMA), Ecstasy (MDMA, XTC, X, E, Adam) is a syn- rape drugs also called “Adam” and “XTC” thetic, psychoactive, hallucinogenic drug, • The date rape drugs GHB, flunitrazepam first synthesized in Germany by Merck in (known mainly by its brand name, 1914 to facilitate communication during psy- Rohypnol), and ketamine chotherapy.8 It is an amphetamine analogue • Herbal ecstasy, another name for ma and a selective serotonergic neurotoxin. huang or ephedra Experimentation in humans has been traced • Methamphetamine. back only to the early 1970s.9 Its use was The makeup of these designer drugs, as criminalized in the United States in 1985,9 by well as their desired effects, their short-term which time it had jumped from the psychia- and long-term adverse effects, and how to trist’s couch to the dance floor. manage overdose are discussed later in this Much of what is sold as ecstasy is not pure article. MDMA, but may be any combination of 3,4- Ecstasy. In a random survey of illicit drug methylenedioxyamphetamine (MDA, the use in undergraduates attending Tulane love pill, the love drug, or speed for lovers), University in 1990, use of ecstasy was report- N-ethyl-methylendioxyamphetamine (MDE, ed by 24% of those surveyed.5 In 1996, 5% of Eve), lysergic acid diethylamide (LSD), US 16-year-olds reported ecstasy use. 6 amphetamine, caffeine, heroin, or lactose. According to the 1999 Monitoring the Future MDE produces effects similar to those of Study,3 4.4% of 10th graders and 5.6% of 12th MDMA but turns the subject inwards. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 543 ILLICIT DRUG USE ROME TA B L E 1 The release of neurotransmitters also decreases body temperature perception, and Commonly abused drugs users of MDMA can overheat without feeling associated with serious heat injury any discomfort (TABLE 1). or rhabdomyolysis Amphetamines The ecstasy ‘rush’ Ingestion of ecstasy is followed by an almost Cocaine instantaneous “rush,” occurring in approxi- MDMA (ecstasy) mately 30 to 45 seconds if taken on an empty Methamphetamine (crystal meth, ice) stomach. This rush lasts 15 to 30 minutes and Phencyclidine (PCP) 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 How ecstasy is taken and crisper” and feeling an inner sensation of MDMA comes in the form of a white, crys- happiness, with people seeming lovable exact- talline powder which can be buffered and ly as they are. At this point users usually take pressed into pills.10 The usual dose taken by a booster dose of MDMA to prolong these young people is 1 to 2 mg/kg body weight (125 feelings. Unfortunately, booster doses increase to 180 mg). A 100-mg tablet usually costs tolerance to the desired effects and an increase around $20. It may be ingested orally, placed in the adverse effects of coming down. under the tongue, added to juice or a carbon- “Bubble bursting” refers to a buildup of ated beverage, or snorted intranasally. anxiety, fear, stomach tightness, nausea, or “Candyflipping” is the intentional com- panic instead of the expected rush. bination of ecstasy with LSD. Thirty minutes to 3 hours after the initial “Stacking” means taking three or more “coming on,” or perception of enhanced feel- tablets at once, or mixing MDMA with LSD, ing, users experience a “plateau” phase of less- A 100-mg alcohol, or marijuana in order to modulate the intense feelings. During the plateau, repetitive tablet of high. Those who stack may take different or trance-like movements become extremely drugs at different times throughout an evening pleasurable, leading to long-lasting ecstatic ecstasty costs to modify their high: eg, they start with ecsta- states of “trance dancing.” Rhabdomyolysis $20 sy, add amphetamine or cocaine while coming can easily occur during this phase of extended down, and add cannabis, alcohol, GHB, or activity. ketamine as the evening continues. Stacking The “coming down” phase occurs 3 to 6 increases the risk of overdose, as the stimulant hours after initial ingestion. During this phase, effects of MDMA may mask the sedative feelings of disappointment and other negative effects of alcohol or opiates. Moreover, alco- emotions (eg, depression, anxiety) can hol use can induce diuresis, further augment- emerge, with sluggishness and residual effects ing the risk of dehydration from the marathon lasting up to several days. It may take up to 6 dancing typical at raves. to 7 hours to fall asleep after returning to “nor- mal,” despite extreme exhaustion. How ecstasy works MDMA has a half-life of 6 hours, and the time Adverse effects of ecstasy to onset of action varies greatly from person to Serious rhabdomyolysis can occur with use of person. It works by releasing serotonin and MDMA and other drugs (TABLE 1). Other side dopamine into the brain. This surge of sero- effects of MDMA are listed in TABLE 2. tonin creates the feeling of love or ecstasy, In the short term, coming down is associ- extending to all people with whom the user ated with a relative depletion of serotonin; the comes into contact. The release of dopamine result is called the “Tuesday blues,” a sluggish keeps the user from feeling any pain. Thus, a feeling lasting several days after ingestion. user may dance for hours on a broken ankle The long-term effects of MDMA use are without realizing it. being studied. Experts suspect that it may 544 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 short-circuit the serotonin pathway with TA B L E 2 repeated use over the long term, potentially causing a shortage of serotonin and subse- Adverse effects of MDMA quent depression. At the present time, how- (ecstasy) use ever, this concept is purely speculative. Addiction (to concurrently used substances, eg, amphetamines, heroin, cocaine) Management of overdose Arrhythmias MDMA is metabolized in the liver to MDA, Coagulopathy (disseminated intravascular) which is then excreted in the urine; thus, typ- Confusion ical urine drug tests may only detect MDA. Coma Urine toxicology testing picks up certain other drugs that may have been simultaneous- Death ly ingested, including cannabis, hallucino- Dehydration gens, phencyclidine (PCP), or stimulants. Electrolyte imbalances Assessing the serum blood alcohol level can Fatigue be useful. A monoclonal immunoassay for Heat injury (fatal, sometimes referred to as amphetamine or methamphetamine detects “Saturday night fever”) MDMA if the drug was taken in large doses.8 Hepatic toxicity Thin-layer chromatography can also detect Jaw-clenching MDMA metabolites in the urine. Whenever Muscle spasms amphetamines are found on immunoassay Pregnancy (unwanted) screening tests, the results can be confirmed Rape by gas chromatography or mass spectrometry. Renal failure (acute) Management of acute heat injury in Tachycardia MDMA users includes rapid rehydration and Teratogenicity core cooling. Management of rhabdomyolysis involves rehydration, correction of electrolyte imbalances, urine alkalinization, and use of GHB‘s effects furosemide as needed. Short-acting benzodi- vary greatly azepines can be administered intravenously or tectable when mixed with beverages. intramuscularly for patients with extreme agi- Developed as an adjunct to anesthesia, from person tation, panic reactions, or seizures. Neurologic GHB was believed in the 1970s to have clini- to person assessment and vital signs should be checked cal value in the treatment of narcolepsy. In the frequently. Dantrolene may be useful in coun- 1980s, it was used by weight lifters to increase teracting MDMA-associated muscle spasms; the metabolic rate. In the 1990s, “blue nitro,” beta-blockers, calcium channel blockers, or a GHB precursor, was used as a weight-loss procainamide may be required to treat cardiac preparation, while Serenity, another GHB pre- arrhythmias. If a patient seems likely to injure cursor, was used by body builders. GHB’s pur- himself or others, a quiet, dark setting with ported medicinal value was eventually over- judicious use of benzodiazepines is imperative. shadowed by its unpredictability: a given dose could completely anesthetize one patient and s GAMMA-HYDROXYBUTYRATE (GHB) have no effect on another. GHB—also known as liquid ecstasy, easy lay, How GHB works grievous bodily harm, cherry meth, soap, GHB’s central nervous system effects include growth hormone booster, gook, liquid X, liq- mediation of sleep cycles, temperature regula- uid G, and liquid E—is a precursor of the neu- tion, cerebral glucose metabolism and blood rotransmitter gamma aminobutyric acid flow, memory, and emotional control.11 The (GABA) that acts on the dopaminergic sys- onset of action is within 15 to 60 minutes, and tem. GHB is usually sold as a salty, clear liquid effects last from 1 to 3 hours. The half-life is in small bottles and is taken by the capful. It 27 minutes, with elimination by expired is also available in capsule form. GHB is unde- breath as carbon dioxide. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 545 ILLICIT DRUG USE ROME Desired effects of GHB s KETAMINE Young people take GHB to experience euphoria, disinhibition, and sexual enhanc- Ketamine (special K, vitamin K, new ecstasy, ing effects without an appreciable hang- ketalar, ketaject, psychedelic heroin, and over.12 super K) is a shorter-acting, less potent alter- native to PCP. It is used by veterinarians as an Adverse effects of GHB anesthetic, is available in both liquid and The concentration may vary, so the response powder forms and has a bitter taste. The liquid is idiosyncratic. Patients may experience form is usually ingested orally or intravenous- either mydriasis or miosis, another indication ly. In white powder form it is either snorted by of the inconsistent response from person to itself or smoked with marijuana or tobacco. person. In severe cases, the classic triad of The powder can be made from the liquid by symptoms includes coma, bradycardia, and gently boiling on a stove or in the microwave. myoclonus. Hallucinations can also occur. Dose-to-dose variability in effects is com- As the patient starts to recover, “emer- mon, and the effects are potentiated by alco- gence phenomena” can occur, characterized hol, barbiturates, opiates, GHB, and valium. If by myoclonic jerking motions, transient con- taken intramuscularly, effects occur within 2 fusion, and combativeness, followed by rapid minutes. If taken orally, effects occur within recovery of consciousness.11,12 15 to 20 minutes, or sooner on an empty Other effects include delusions, depres- stomach. If taken intranasally, the dose is sion, altered mental status, apnea, hypoten- repeated every 5 minutes until the desired sion, nausea, vomiting, vertigo, respiratory effects are achieved. distress, transient metabolic acidosis, loss of airway reflexes, ataxia, nystagmus, aggressive Desired effects of ketamine behavior, somnolence, anterograde amnesia, Effects last 2 to 3 hours. Low doses lead to feel- and coma. ings of relaxation, and high doses bring on a Adverse effects are potentiated by alco- sensation of a near-death experience (known High doses hol, ketamine, benzodiazepines, major tran- as the “K-hole”) and loss of sense of time and of ketamine quilizers, opiates, anticonvulsants, and over- identity. “K-land” refers to hallucinations and the-counter cold and sleep medicines. All of visual distortions. The user feels no pain, a can produce the above can exacerbate respiratory depres- state that can lead to unintentional injuries ‘K-hole,‘ sion. Use with methamphetamine increases the user may not be aware of until he or she the risk of seizure. comes down. a near-death experience Management of GHB overdose Adverse effects of ketamine Management of GHB overdose consists of Short-term physical effects include tachycar- supportive therapy, including prevention of dia, hypertension, impaired motor function, aspiration. Intravenous fluids and oxygen respiratory depression, bronchodilation, pap- may be required, and atropine should be used illary dilation, and nausea. Short-term psy- in patients with persistent symptomatic chologic effects include dissociation, depres- bradycardia. In severe cases, rapid intubation sion, recurrent flashbacks, delirium, and with succinylcholine paralysis may be amnesia. required for advanced airway protection. 13 If Long-term adverse effects are currently abuse of multiple drugs is suspected, orogas- unknown, but brain damage has been tric lavage and administration of activated observed in animal studies. Persons who use charcoal with sorbitol is recommended. If the ketamine while taking antibiotics (eg, patient is still intoxicated at 6 hours after ofloxacin), anticholinergics, antipsychotics, ingestion, hospital admission is warranted. bupropion (Wellbutrin and Zyban), caffeine, Otherwise, if alert, responsive, and normal or GHB increase their risk of seizure. Under on physical examination 6 hours after inges- the drug’s short-term effects, the user may tion, the patient can be discharged from the remain so immobile as to become hypother- emergency room. mic. 546 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 Management of ketamine overdose ephedra nor its extracted form ephedrine are Neuroleptic drugs are ineffective in control- regulated by the US Food and Drug ling the unpleasant mental and visual side Administration. effects of ketamine.14 The clinician should watch for oversedation, protecting the airways Desired effects of herbal ecstasy as necessary. The effects of herbal ecstasy last 3 to 4 hours when taken orally. Three tablets taken s ROHYPNOL together have an effect similar to ampheta- mines or a large dose of caffeine. Rohypnol, (the date rape drug, ruffies, roofies, rouches, the forget pill) is licensed in Europe, Adverse effects of herbal ecstasy Asia, and Latin America as an anti-seizure Adverse effects include tachycardia, hyper- drug. It is a benzodiazepine 10 times more tension, stroke, seizure, myocardial infarction, potent than diazepam (Valium). It is sold as and death. The doses needed to produce these individually wrapped tablets that are colorless, effects are not known. These substances are odorless, and tasteless when mixed in bever- not regulated by the Food and Drug ages. Administration, and it is hard to know exact- ly how much of any given substance a product Desired effects of rohypnol contains. Desired effects include disinhibition, amnesia, and muscle relaxation, but individual effects Management of overdose vary. An overdose of herbal ecstasy may be associ- ated with restlessness, muscle spasms, tachy- Adverse effects of rohypnol cardia, dry throat, and cold extremities. Adverse effects include sedation, respiratory Neither ephedra or ephedrine should be used depression, impaired motor coordination, by people with cardiac problems or high blood confusion, memory loss, hallucinations, and pressure. Hypertension in persons who have potential overdose when combined with alco- overdosed on herbal ecstasy may respond to Metham- hol. Paradoxically, it may cause aggressiveness the use of benzodiazepines to decrease anxiety. phetamine in some cases. Nitroprusside should be used in hypertensive crisis. is a highly Management of rohypnol overdose addictive Rohypnol is not detectable with routine urine s METHAMPHETAMINE toxicology screening. Airway protection and stimulant blood pressure control may be warranted. Methamphetamine (ice, crystal meth, speed, Midazolam (Versed), used as a sedative before tweak, crank, glass, or tina) is a highly addic- endoscopy, can be used in severe cases to tive stimulant that causes the release of large reverse benzodiazepine effects, but longer amounts of dopamine, enhancing mood and observation would be indicated. body movement. It is sold either as a white powder that is taken orally, intranasally, intra- s HERBAL ECSTASY venously, or rectally, or as a clear, crystal- shaped “rock” that is heated and smoked like Herbal ecstasy (ma huang, ephedra) is used as crack cocaine. The smoked form is called ice, a stimulant or a weight-loss agent and is avail- crystal, and glass. able at many health food stores and by mail order from sources advertised in drug culture Desired effects of methamphetamine magazines. It is an ingredient in some Chinese Smoking and intravenous use give a rush herbal medications and in nutritional supple- described as an intense, very pleasurable sen- ments such as Metabolift and Metabolife 356. sation that lasts a few minutes. Intranasal and A 300-mg dose of ephedra is equivalent to 30 oral use do not produce this rush, but rather a mg of ephedrine. Ephedrine is found in many “high.” Effects occur within 3 to 5 minutes over-the-counter cold preparations. Neither with intranasal use and within 15 to 20 min- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 547 ILLICIT DRUG USE ROME utes with oral use, and can last up to 24 hours. tetramethylene glycol and 2(3H)-furanone di- hydro. Adverse effects of methamphetamine Adverse effects of methamphetamine use Smart drinks include a wide variety of physical and psycho- In addition to alcohol, marijuana, cocaine, logical effects: eg, wakefulness, increased phys- and amphetamines, other substances associat- ical activity (a hyperalert state, restlessness), ed with the rave subculture are stimulants decreased appetite, headache, mydriasis, sen- called “smart drinks” (see “The rave scene: a sation of hair “standing on end,” vasoconstric- closer look, page 542), also called “power tion of extremities, dry mouth, hyperreflexia, drinks,”which are used to prevent dehydra- tremors, tachycardia, hypertension, palpita- tion. They are sold at both raves and nutrition tions, cardiac arrhythmias, cardiomyopathy, stores and come in bottles or cans or as pow- stroke, hyperthermia, seizures, euphoria, irri- ders or capsules. They may contain ma huang, tability, insomnia, anxiety, hallucinations, caffeine, guarana (a stimulant similar to caf- paranoia, psychosis, and death. feine), ginseng, amino acids, taurine, sugars, Methamphetamine may cause degenera- tryptophan, and high doses of B and C vita- tion of neurons containing the neurotrans- mins. mitter dopamine, with damage of these neu- rons known to be the underlying cause of the Go-go drinks motor disturbances seen in Parkinson dis- Go-go drinks, similar to power drinks, are also ease. sold at raves and contain ginseng, yohimbine, and guarana. They are marketed as “Viagra for Management of methamphetamine overdose women.” They are used to boost energy levels, Effects of methamphetamine tend to last 5 to to increase stamina, to quench thirst, and to 10 hours. The drug is metabolized to amphet- enhance concentration. Most contain stimu- amine. Urine toxicology screening may pick lants. Taken in excess they can cause nausea, up both methamphetamine and ampheta- loss of appetite, insomnia, tachycardia, visual Stimulant- mine. Gas chromatography and mass spec- and sensory impairment, and bladder and uri- containing trometry can differentiate methamphetamine nary tract discomfort. People with heart or from amphetamine. kidney disease, hypertension, hypotension, drinks are used In case of overdose, haloperidol can be asthma, and diabetes mellitus should not use to prevent used to control agitation, and benzodiazepines them. can be used to control seizures. Hypertension dehydration can be managed with intravenous beta-block- s MANAGING DESIGNER DRUG ABUSE: ers. Cardiac monitoring and precautions to ADDITIONAL CONSIDERATIONS prevent seizure are usually indicated. Some patients may require airway protection. Urine and serum toxicology screens may not be able to detect club drugs. For example, s OTHER CLUB DRUGS urine screening does not detect MDMA, though it does detect its metabolite, MDA. GHB precursors Urine screening does not detect LSD, A commonly found GHB precursor is gamma- inhalants, alcohol, benzodiazepines such as butyrolactone (GBL), also known as blue alprazolam (Xanax) and lorazepam (Ativan), nitro, gamma-G, renewtrient, reviverent. and methylphenidate (Ritalin). Thin-layer GBL is an organic solvent used for cleaning chromatography can be requested, specifying circuit boards, stripping paint, or flavoring soy suspected drugs based on the history and phys- products. It acts like GHB but has a slower ical examination. onset and a longer duration. Adverse effects The patient should be placed in a warm, include respiratory depression and cardiac dys- dark room. When possible, the patient and rhythmia. It is metabolized in the liver into friends should be questioned as to what drugs GHB but can also be made into GHB using were ingested and in what form. home kits. Other precursors to GHB include In crisis situations, stabilize the patient 548 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 TA B L E 3 TA B L E 4 Ocular effects Cardiovascular effects of commonly abused drugs of commonly abused drugs Conjunctival injection Arrhythmia Lysergic acid diethylamide (LSD) Amphetamines/stimulants Marijuana Cocaine Miosis Inhalants Alcohol Opiates Barbiturates Phencyclidine (PCP) Benzodiazepines Hypertension Opiates Amphetamines/stimulants Phencyclidine (PCP) Cocaine Mydriasis Lysergic acid diethylamide (LSD) Alcohol or opiate withdrawal Marijuana Amphetamines/stimulants PCP Cocaine Withdrawal from alcohol, barbiturates, Glutethimide benzodiazepines Jimson weed Hypotension LSD Barbiturates Nystagmus Marijuana (orthostatic hypotension) Alcohol Opiates Barbiturates Tachycardia Benzodiazepines Amphetamines/stimulants Inhalants Cocaine PCP LSD Marijuana Tearing (excessive lacrimation) PCP Inhalants Withdrawal from alcohol, barbiturates, Questioning LSD benzodiazepines Opiate withdrawal should be adolescent- sensitive while getting as much history as possible from about confidential, unless there is something both patient and accompanying peers. Fear life-threatening or dangerous going on, in and concern for a friend may get them to which case I will need to talk to your parents share more details than they would otherwise or your friends’ parents about this”. reveal at a risk of incriminating themselves. It is often easier for teens to talk about Be nonjudgmental but informative, and avoid their friends’ use prior to discussing their own lecturing the patient. use, so when and how one asks the questions If the patient is comatose, the “ABCs” will have a big impact on how much informa- apply: airway, breathing, circulation. TABLE 3 tion you can learn. lists the ocular findings associated with use of Club drugs continue to be modified and different drugs, and TABLE 4 lists cardiovascular evolve, making them very difficult to moni- findings. tor. It is useful to know what drugs are being used in your community. Information can be s HOW TO STAY INFORMED gleaned from teens themselves at both rou- tine and emergency visits, from local sub- If the patient is a teenager, questioning needs stance abuse programs, and from the police. It to be “adolescent-sensitive,” establishing con- is also useful to know what resources are fidentiality yet defining the limits of that con- available in your community: eg, teen hot- fidentiality: “I will keep everything we talk lines, substance abuse programs, health edu- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001 549 ILLICIT DRUG USE ROME cators, websites. Online resources When parents ask if they should do a Physicians and parents can use many on-line room search, the health care provider should resources, such as the National Clearinghouse ask what the parent(s) plan to do with the for Alcohol and Drug Information, at information. If the search finds nothing, the www.health.org, or the National Institute on parent may assume that the teen is hiding the Alcohol Abuse and Alcoholism, at drugs elsewhere. If it is positive, the parents www.niaaa.nih.gov, or the Monitoring the must confront the teen anyway, creating a big- Future Study at www.isr.umich.edu/src/mtf. ger problem of violated trust, with the teen Other parental/community resources include often successfully diverting attention away Mothers Against Drunk Driving, at from his or her substance abuse in order to www.madd.org, and Al-Anon/Alateen Home address issues of privacy. Page, at www.al-anon.alateen.org. s REFERENCES 1. American Academy of Pediatrics, Committee on Substance 8. Schwartz P, Miller N. MDMA (ecstasy) and the rave: a Abuse. Tobacco, alcohol, and other drugs: the role of the review. Pediatrics 1997;100:705–708. pediatrician in prevention and management of substance 9. Beck J, Rosenbaum M. Pursuit of ecstasy—The MDMA abuse. Pediatrics 1998; 101:125–128. experience. Albany: State University of New York Press, 2. National Institute on Drug Abuse. Monitoring the Future 1994. Study. Rockville, MD: National Institute on Drug Abuse, 10. Eisner B. Ecstasy—the MDMA study. Berkeley, CA: Ronin 1996. Publishing, 1989. 3. U.S. Department of Health and Human Services. 11. Li J, Stokes SA, Woeckener A. A tale of novel intoxication: Monitoring the Future. National Results on Adolescent seven cases of gamma-hydroxybutyrate acid overdose. Ann Drug Use. Overview of Key Findings. National Institute on of Emerg Med 1998; 31:723–728. Drug Abuse. 1999 NIH Publication No. 00-4690. 12. Chin RL, Sporer KA, Cullison B, Dyer J, Wu TD. Clinical 4. U.S. Department of Health and Human Services. 2000 course of gamma-hydroxybutyrate overdose. Ann of Emerg Monitoring the Future Study: High school and youth Med 1998; 31:716–722. trends. Available from: www.nida.nih.gov/Infofax. 13. Li J, Stokes SA, Woeckener A. A tale of novel intoxication: 5. Cuomo MJ, Dyment PG, Gammino VM. Increasing use of review of the effects of gamma-hydroxybutyric acid with “ecstasy” (MDMA) and other hallucinogens on a college recommendations for management. Ann Emerg Med 1998; campus. J Am Coll Health 1994; 42:271–274. 31:729–736. 6. Johnston LD, O’Malley PM, Bachman JG. National survey 14. Oye I. Ketamine analgesia, NMDA receptors, and the gates results on drug use from the Monitoring the Future Study, of perception. Acta Anaesthesiol Scand 1998; 42:747–749. 1975–1994. Volume 1. Secondary school students. Rockville, Maryland: National Institutes of Health, 1995. ADDRESS: Ellen S. Rome, MD, MPH, Section of Adolescent 7. Schwartz R, Weaver A. Rohypnol, the date rape drug. Clini Medicine, A120, The Cleveland Clinic Foundation, 9500 Euclid Pediatr (Phila) 1998; 37:321–322. Avenue, Cleveland, OH 44195; e-mail email@example.com. Clinical vignettes and questions on the INTERNAL differential diagnosis and treatment of MEDICINE medical conditions likely to be encountered BOARD on the Qualifying Examination in Medicine — as well as in practice. REVIEW Take the challenge. IN THIS ISSUE PAGE 561 550 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 6 JUNE 2001
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