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It's a rave new world Rave cultu



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, 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 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

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
                                                                              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

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-
ical urine drug tests may only detect MDA.
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
MDMA users includes rapid rehydration and
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.

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-
                      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

 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
   Tearing (excessive lacrimation)                      PCP
   Inhalants                                            Withdrawal from alcohol, barbiturates,               Questioning
   LSD                                                    benzodiazepines
   Opiate withdrawal                                                                                         should be
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            , 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          , or the Monitoring the
                    must confront the teen anyway, creating a big-                     Future Study at
                    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              , and Al-Anon/Alateen Home
                    address issues of privacy.                                         Page, at

                     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:             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

                                                              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


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