Club Drugs: Their Epidemiology, Biology and Psychological Impact

from School Health Reporter, Winter 2004

By Eric Sigel, MD, The Children's Hospital

Though novel in the early ’90s, club drugs have become mainstream in today’s drug scene. Their roots come from the club/rave settings. We have witnessed a dramatic rise in the use of Ecstasy specifically, and it is helpful for school personnel to understand the epidemiology, biology and psychological impact of these drugs on our teenagers and young adults.

Raves

Recognizing what raves are is important to understanding the evolution of club drugs into popular culture. Raves began in the late ’80s; they are all-night dance parties that began underground, hidden from the law and from conventional culture. They represented an alternative to mainstream socialization, an outlet for teens and young adults who did not identify with the popular peer groups. Because of the desire to stay separate and away from the law, notices would go out at the last moment, letting concert-goers know where the upcoming event was being held – usually in abandoned warehouses and remote areas of the countryside. The music initially was noncommercial, computer-generated that reflected the techno age. It has been described as repetitive, remorseless, loud and fast, surging past the listener in mind-numbing waves. Over the last 10 to 15 years, the music of raves has evolved into a new genre, appealing to a wide range of teenagers and adults. Different types of music within this genre that have arisen are referred to as “techno,” “house” and “trance,” among others. Raves also have become mainstream.  It is easy to log on to the Internet and find where a rave is being held on any given night. Concert promoters sponsor raves at the major concert venues in every city.

The link between raves and drugs can be found in part by the nature of raves. Typically raves last all night. Dancing to techno music is an essential component of the rave. Drug use helps participants stay up all night, and then come down when dawn arrives. Additionally, the hallucinogens enable people to dismiss classic social barriers and let them connect to peers – regardless of sex, ethnic background or social class. Some of the more frequently used drugs at raves include Ecstasy, GHB, ketamine, rohypnol and methamphetamine.

Ecstasy

Ecstasy is an amphetamine that has hallucinogenic properties similar to mescaline. People use Ecstasy to achieve the effect of increasing one’s sensory input. People report that they feel extremely happy, peaceful and euphoric with enhanced sensation from touch and other sensory systems. Social inhibitions disappear, sexual sensation is increased and people feel close or connected to others. Originally psychiatrists used Ecstasy with their patients, as it was found to decrease patients’ inhibitions, allowing them to talk freely and openly. Once the physical danger of Ecstasy was realized, it became a banned substance.

Ecstasy is the one drug whose usage has increased dramatically over the last five years, though for the first time in 2001 the rate of increase has slowed somewhat. Nearly 12 percent of high school seniors have tried Ecstasy at least once in their lifetime. There has been increased media attention focused on Ecstasy use, both due to the rapid rise in use as well as much-publicized deaths from using Ecstasy. Ecstasy is readily available, with more than 50 percent of high school students saying they could obtain it easily. Ecstasy comes in a tablet form that is often branded, as Playboy bunnies, Nike swoosh, CK. People believe that each insignia means it has a slightly different effect. It can be made in home labs, though most often it is imported from Europe . Studies have shown anywhere from 0 mg to 140 mg of MDMA present in any given pill.  Average dose is 100 mg. One teaching point for patients is that one has no control over what is actually in the tablet; it may be cut with any one of a number of drugs that are undesirable to the user. Ecstasy is taken orally in pill form. Onset of action begins 20 minutes after ingestion and can last up to six hours. Toxicity is potentiated when taken with alcohol.

Deaths from Ecstasy use have been attributed to a wide range of medical complications, including muscle breakdown, elevated body temperature, blood clotting abnormalities, liver damage, heart arrhythmias, stroke and suicide. Studies have shown impaired cognitive performance occurring in those individuals who have used Ecstasy recreationally, performing worse in complex tasks of attention, memory and learning tasks, and tasks that reflect general intelligence. Performance is worse with heavier use of Ecstasy.

Short-term psychological difficulties associated with Ecstasy use include confusion, depression, sleep problems, drug craving, severe anxiety and paranoia, during and sometimes weeks after taking the drug. Additional psychologic effects include increased physical complaints, obsessive thoughts and hostility.

There are myths about Ecstasy use that school personnel will encounter frequently with the students they work with. Many believe that if one uses Ecstasy “the right way” there will be no adverse effects. The right way includes drinking the appropriate fluids, not getting overheated and having enough energy in the system. As with any drug, people believe they cannot get addicted to Ecstasy, which is false. Since there is so much appeal to Ecstasy use, counseling is important in the early teen years.

Street names/slang terms: Adam, Bean, E, Ecstasy, M, Roll, X, XTC, Lovers Speed.

Gamma-Hydroxybutyrate (GHB)

GHB is a sedative/memory impairment agent that often is used at the end of a rave to help people come down from their Ecstasy high. The body has been stimulated by Ecstasy, and then is slowed down by GHB. It has been used outside the United States to treat narcolepsy, opiate and ethanol withdrawal. It was commonly used as an anesthetic, though other agents that are more effective have largely supplanted its use.

Since about 1990, GHB has been abused in the United States for euphoric, sedative and bodybuilding effects. It is a central nervous system depressant that was widely available over the counter in health-food stores during the 1980s until 1992. It was purchased mostly by bodybuilders to aid fat reduction and muscle building. It is now more common as a club drug. Additionally, because of its memory impairment properties, GHB is one of the most common date rape drugs. GHB can be produced in clear liquid, white powder, tablet and capsule forms, and is tasteless if mixed in drinks. Similar to other club drugs, it can be made in home laboratories. Because of its toxicity, overdoses presenting to emergency rooms have increased dramatically, from 55 in 1994 to 2,973 in 1999. In 1999, GHB accounted for 32 percent of illicit drug-related poison center calls in Boston . When examining the prevalence of use in high school, 1.6 percent of high school seniors report having used GHB in the last year.

Street names/slang terms: Liquid Ecstasy, Soap, Easy Lay and Georgia Home Boy

Ketamine

Ketamine is an injectable anesthetic that has been approved for both human and animal use in medical since 1970. About 90 percent of the ketamine legally sold today is intended for veterinary use. Ketamine gained popularity for abuse in the 1980s, when it was realized that large doses cause reactions similar to those associated with use of PCP, such as dream-like states and hallucinations.  Ketamine is produced in liquid form or as a white powder that is often snorted or smoked with marijuana or tobacco products. Recently ketamine is reportedly being injected intramuscularly. Eighth graders report a 1.3 percent use in the last year, and twelfth graders report a 2.5 percent use in the last year. Drug abusers seek the delusional effects of ketamine. Neurologic effects include sedation, anxiety, agitation, slurred speech, dilated pupils and psychotic symptoms such as delusions and hallucinations.  Systemic effects include increased heart rate/blood pressure, palpitations, chest pain and rapid respirations.  Higher doses can lead to respiratory depression. Lowdose intoxication from ketamine results in impaired attention, learning ability and memory.

Street names/slang terms: Special K, K, Vitamin K, Cat Valium Rohypnol

Rohypnol

Rohypnol (flunitrazepam) is a benzodiazepine that is not approved for prescription use in the United States , although it is approved in Europe and is used in more than 60 countries as a treatment for insomnia, as a sedative and as a presurgery anesthetic.

Relatively few adolescents admit to using Rohypnol, approximately 1.7 percent of high school seniors have used during their lifetime. About 1 percent of eighth and twelfth graders have used Rohypnol in the last year.  Rohypnol causes profound “anterograde amnesia;” individuals may not remember events they experienced  while under the effects of the drug. The amnesia achieved makes the drug attractive as a “date rape drug.”

Individuals become amnestic but do not necessarily lose consciousness. It is tasteless and odorless, and it dissolves easily in carbonated beverages. The sedative and toxic effects of Rohypnol are aggravated by concurrent use of alcohol. Even without alcohol, a dose of Rohypnol as small as 1 mg can impair a victim for eight to 12 hours. Rohypnol is a CNS depressant. Individuals get sedated, become drowsy and may lose consciousness. Other side effects associated with Rohypnol include decreased blood pressure, respiratory depression, visual disturbances, dizziness, confusion, nausea, vomiting and urinary retention.

In counseling adolescents and young adults, it is essential to remind them to always be on the lookout for themselves and each other, specifically if they are at parties or in bars where they do not know everyone. They need to know exactly where a drink came from and who made it, as it is easy to dope any drink in that kind of setting. Encouraging women to buddy-up with others, consistently checking in with each other during an evening is one way to prevent negative consequences such as sexual assault.

Street names/slang terms: Roofies, Rophies, Roche, Forget-me Pill

Methamphetamine

Methamphetamine or crystal methamphetamine continues to be used by approximately 2.2 percent of eighth graders and 6 percent of high school seniors annually; high school seniors report a 10.9 percent rate of use over their lifetime. In 2000, there was a 30 percent increase from the previous year of people presenting to emergency rooms for methamphetamine overdoses. Crystal meth has received much media attention as meth lab busts by police are increasing substantially, consuming significant resources of local drug agencies. It is easily made using a combination of over-the-counter products including cold preparations that have pseudophedrine. Methamphetamine can be taken orally, injected, snorted or smoked.

Immediately after smoking or intravenous injection, the catecholamine release causes the methamphetamine user to experience an intense sensation, called a “rush” or “flash,” that lasts only a few minutes and is described as extremely pleasurable. Oral or intranasal use produces euphoria – a high, but not a rush. Other short-term effects include irritability/aggression, anxiety, nervousness, convulsions and insomnia. Generally, methamphetamine has similar sympathomimetic side effects as Ecstasy.

Street names/slang terms: Chalk, Crank, Croak, Crypto,  Crystal , Fire, Glass, Meth, Speed, White cross

Screening

In-depth drug use assessment is beyond the scope of this article. Primary care health providers should recognize that the use of these club drugs is higher in any adolescent who is demonstrating “at risk behavior.” Earlier age of onset of any drug use, younger age of sexual debut and academic difficulties are just a few of the risk factors that are associated with drug use. This does not exclude high-functioning teenagers, as they may experiment out of boredom or curiosity. Adolescents and young adults should be asked about the availability of MDMA, what their philosophy is on using Ecstasy, and whether they have experimented. Counseling about side effects and acute risk is essential. Use of any amphetamine puts the user at risk for death the next time they use. Some practitioners believe use of these substances is reason to bring parents into the discussion, breaking confidentiality if a patient is in imminent danger.

Evaluating for the presence of depression or other mental health disorders is essential, and can help the practitioner determine the appropriate course of intervention.  If the patient seems to be truly addicted, then referral to a drug treatment program is indicated. If a patient has been experimenting, and there appears to be comorbid psychiatric issues, then treating depression, for example, with counseling and medication is appropriate.  As part of the treatment, one can use drug screening to help monitor the teen’s drug use. Though most drugs are metabolized within a few days, performing random Monday urine drug screening can be an adjunct to treatment.

Counseling those adolescents going to college on what they may be exposed to, as well as their responsibilities, is an additional topic to pursue. These club drugs have potentially high morbidity and mortality, and adolescents should be made aware of the facts so informed decisions can be made in regard to their choice to use. The availability and properties of the date rape drugs could make the idea of sexually victimizing peers more enticing.  Females need to be aware of how date rape may be perpetrated, and how they can team up with peers to prevent it.  Having a serious conversation with college-age males about morality and legal aspects of date rape also should be pursued.

Practitioners should familiarize themselves with drug treatment resources in the community. Schools often have mini-courses on drug use. Most cities certainly have drug treatment facilities that can help assess an adolescent for extent of drug use and whether significant intervention, such as residential treatment or day treatment, is indicated.  Adolescent specialists can be relied upon to help the primary care practitioner work through complicated situations.