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Club Drugs Understanding What They Are, Why People Use Them, and What They Do. Thomas E. Freese, Ph.D. Director, Pacific Southwest Addiction Technology Transfer Center Director of Training, UCLA Integrated Substance Abuse Programs July 7, 2006. The Club Drugs. THE BIG ONES -

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Club DrugsUnderstanding What They Are, Why People Use Them, and What They Do

Thomas E. Freese, Ph.D.

Director,

Pacific Southwest Addiction Technology Transfer Center

Director of Training,

UCLA Integrated Substance Abuse Programs

July 7, 2006


The Club Drugs

  • THE BIG ONES -

  • 3,4 methylenedioxymethamphetamine (Ecstasy)

  • Gamma Hydroxy Butyrate (GHB)

  • Ketamine

  • Nitrous Oxide

  • SOME NEW ONES

  • 2C-B

  • DXM


MDMA


Ecstacy Tabs


Ecstasy

  • MDMA technically 3,4 - Methylenedioxymethamphetamine

  • Hallucinogenic amphetamine

  • Releases serotonin and blocks reuptake

  • Dopamine and adrenergic effects


Ecstasy History

  • Developed and patented in Germany in 1912 by Merck

  • Stimulant properties were identified in 1933

  • Scientific studies began in the 1970s

  • Used in psychotherapy in 70’s and early 80’s

  • MDMA emerged in mid 1980s on the “Rave Party Scene”

  • DEA Schedule 1 in 1985


Patterns of useThe Picture in the Late ‘90s

  • Third most used illicit drug

  • Used recreationally

  • Youth culture centered on “raves”

  • Trend in increase of injection


Percentage of Seniors Reporting Ecstasy as ‘Fairly Easy’ or ‘Very Easy’ to get

Source: Monitoring the Future Study, 1999 -- NIDA


Ecstasy Rates by Grade 2003-2005

SOURCE: Monitoring the Future Study, 2005.


Poison Control Center Calls for Major Substances of Abuse: 2000-2005

Los Angeles County

SOURCE: California Poison Control System, 2006.


Ecstacy Tablets

Anatomy of a Tab

  • different sizes & shapes

  •  Typical X is 300 mg tab

  • 50-150 mg MDMA (maybe less)

  • coloring

  • binders

     coatings


MDMA Packaging

  • Tootsie rolls are softened & X hidden inside-- “Doing rolls” or “Rolling”

  • Skittles--X mixed in

  • Pez containers--they fit


Talk About Creative

  • Beaded necklaces for the pacifiers can be homemade; even the “fuzzies” come in kits.

  • Ravers have gone as far as drilling their X pills & stringing them into candy necklaces.


Ecstacy

X

Dosage & Ingestion

  •  50-150 mg MDMA in one 300 mg tab (lots of variability (50-300 mg/tab)

    •  1-3x a night

    •  $25 per tablet

    •  taken primarily orally

    •  can be injected (IM, not IV)

    • Snorted

       Rectally (“Plugging“)


Ecstacy

Onset & Duration of Effects

Starts:20 – 40 minutes

Peaks:2 – 4 hours

Lasts:Physically: up to 8 hours

Mentally: 24 – 48 hours

Street names: Adam, X, XTC, e

Drug class: Empathogen


Ecstacy

Under the Influence

  •  dilated pupils high temp

  •  elevated pulse  insomnia

  • hyperactive  muscle rigidity

  • grinding teeth  sweating

  • increased sensual perceptions

  • hallucinations rare

CNS STIMULANT


Ecstacy

X

Dilated Pupils


Pharmacological effects

  • Initial enhancement of extracellular seratonin

    • Eventual decrease in seratonin levels

    • Effects are influenced by ambient temperature

  • Elevation of dopamine

    • Mediates effects of cocaine and amphetamine


Long-term effects

  • Neurotoxicity

    • Damage to neurons containing seratonin

    • Abnormalities in brain morphology

  • Short-term memory impairment


BRAIN CHANGES of Ecstasy users as well as people who abstain. Ecstasy users have far less serotonin activity (dark areas). May be permanent.


Effects of MDMA on Serotonin Transporters

The Johns Hopkins Medical Institutions


Subjective Effects of MDMA

  • Altered time perception

  • Increased ability to interact with others

  • Decreased libido

  • Decreased defensiveness

  • Changes in visual perceptions

  • Increased awareness of emotions

  • Less impulsive


Physical effects

  • Pupil dilation

  • Nystagmus

  • Dry mouth

  • Loss of appetite

  • Bruxism (Jaw tension / teeth grinding)

  • Sweaty palms

  • Hot / cold flushes

  • Tachycardia

  • Motor tics

  • Headaches

  • Lethargy

  • Anorexia


Most significant acute adverse effects

  • Hyperthermia

    • Seizures

    • Disseminated intravascular coagulation

    • Renal and liver impairment

    • Rhabdomyolysis

  • Hyponatraemia

    • Confusion

    • Reduced consciousness

    • Seizures or convulsions


Other acute adverse effects

  • Seizures without hyperthermia or hyponatraemia

  • Hemorrhage due to changes in blood pressure

  • Respiratory difficulties

  • Chest pains associated with physical exertion

  • Ophthalmic complications


Psychological effects

  • Euphoria

  • Increased energy

  • Feeling of closeness

  • Depression

  • Increased restlessness

  • Increased anxiety

  • Decreased motivation

  • Anhedonia


Psychiatric sequelae

  • Depression

  • Panic disorders

  • Flashbacks

  • Delusions

Risk is greatest when used repeatedly and in conjunction with other drugs


MDMA

  • Heavy MDMA have memory problems for at least 2 weeks after use - functional consequences

  • Reduction in number of serotonin transporters - PET Studies

  • Damage of serotonin nerve endings

    (Bolla, McCann & Ricaurte Neurology 51, 1998)


Ecstasy users had poorer performance in three general intelligence tests

Journal of Neurology, Neurosurgery, and Psychiatry 2000; 68:719-725


Ecstasy users had poorer short-term memory performance than non-drug users

Journal of Neurology, Neurosurgery, and Psychiatry 2000; 68:719-725


“Ecstasy-like” Drug

  • Paramethoxyamphetamine (PMA) – a dangerous hallucinogen with stimulant properties

  • Releases serotonin

  • Slow onset - people often take more and they may overdose

  • Not new - deaths were reported in 1970s


Street Development

Gamma Hydroxy Butyrate (GHB)


GHB

  • Available in health food supplements until 1992.

  • Odorless liquid, frequently clear with a salty taste

  • Precursor, GBL available until recently in health food supplements


GHB

  • Hypnotic (nonanalgesic) anesthetic

  • Epileptogenic agent in animals

  • Increases growth hormone

  • Promotes slow wave sleep

  • Treatment of narcolepsy

  • Trials for the treatment of opiate and alcohol withdrawal


A Dose of GHB

  • 1 teaspoon (approx 2.5 g) - 4 tablespoons (30 g)

  • Dependent users 25 grams/day (357.14 mg/kg for a 70 kg man)

  • 50-70 mg/kg dose - anesthesia

    >60 mg/kg coma

  • Sleep studies - 50 - 60 mg/kg/night 2 doses

  • Alcohol studies - 50 - 150 mg/kg day divided doses


GHB Users

- Rave/club crowd

- Gay community

- Exotic dancers/ strippers

- Bodybuilders

- Rapists

- Individuals subject to random or mandatory drug testing


  • liquid: clear, odorless, colorless

  • salty taste

  •  solid: white powder usually mixed in water

  •  mixed in drinks to mask taste

  •  one dose = 1/2 to 3 teaspoons (1/2 - 1 cap full)

Gamma Hydroxy Butyrate (GHB)


Gamma hydroxy butyrate

Onset & Duration of Effects

  • Cap concentration varies 500mg-5g

  • Rapidly absorbed, peak concentration 20-60 min

  • Almost completely oxidized to carbon dioxide

  • Readily crosses the blood brain barrier and placenta


GHB

  • Also known as:

    GHB, G, Jib, Scoop, Liquid E, Liquid X, Sodium Oxybate, Woman’s Viagra, Grievous Bodily Harm, Easy Lay, Gamma 10, Salty Water, GH Buddy, Aminos, Blue Nitro, Blue Thunder, Thunder Nectar, Renewtrient, Revivarant, Remforce, Firewater, Invigorate


Analogs of GHB

Blue Nitro, Renewtrient, Revivarant, Remforce, Firewater Serenity, FX, Weight Belt Cleaner, Enliven, Biosul

- 1, 4 butanediol (BD or BDO)

- sold legally as a floor stripper


GHB Indicators

  • Information not collected in standardized measures

  • ER Mentions:

    • 1994 = 55

    • 1999 = 2973

  • 32% of calls to Boston Poison Control involve GHB


Common Depressant Impairment

 depressed  slow slurred speech

 impaired attention  intoxicated like ETOH

 sleep-ish  difficulty concentrating

 under-active  disoriented

 droopy eyelids  bloodshot /watery eyes


Gamma-Butylactone

2(3H) Furanone di-hydro

1,4 Butanediol

Sodium oxybate

Improve sleep

Insomnia

Dancing

Avoid drug testing

Antidepressant

Antianxiety

Socialize

Weight lifting

GHB/GBL Analogs and Reported Uses


GHB Survey

  • Convenience sample - recruited by a news paper advertisement

  • 120 callers

  • 42 came in for an interview

  • Male 76%

  • Caucasian 73%

  • Heterosexual 70%

  • Employed 69%


GHB Use Survey Study N=42

  • How often do you use GHB

    • Every day 21.4%

    • 1-6 days/ week 35.7%

    • 1X/month or less42.9%

  • How many times per day

    • Once28.6%

    • 2-3 times42.9%

    • 4 or more28.6%

  • How much do you use at a time?

    • < 1 capful9.5%

    • 1-3 capfuls73.8%

    • > 3 capfuls14.3%

    • Other2.4%


Euphoria

Increased sexuality

Wellbeing

Relaxation

Talkative

Tranquility

Drowsiness

Optimism

Increased energy

Giddiness

Increased sensitivity to sound

Silliness

Sweaty

Loss of consciousness

Subjective Effects of GHB Reported by > 50% of participants


60 - 30 %

Exhaustion

Sluggishness

Amnesia

Confusion

Clumsiness

29 - 15%

Anxiety

Insomnia

Mumbling

Weakness

29 - 15%

Agitation

Stiff muscles

Babbling

Craziness

Depression

Tremor

Overdose

Pessimism

Sadness

Dizziness

Subjective Effects After GHB Use


FACTORS ASSOCIATED WITH GHB OVERDOSE


After GHB Withdrawal –Clinical Concerns

Severity of “protracted withdrawal” associated with severity acute withdrawal

  • Depression

  • Anhedonia - negative symptoms

  • Panic attacks

  • Tremor

  • Paresthesia

  • Overdose


GHB Withdrawal

  • Tolerance to GHB developed within months of use in this case series

  • Withdrawal was reported by high dose users

    • The onset of withdrawal occurred with in 2-24 hours of last use

  • A spectrum of withdrawal signs and symptoms was seen:

    • Mild: tremor, anxiety, insomnia, mood lability

    • Severe: above plus, delerium, psychosis, autonomic instability, tachycardia, blood pressure elevation, extreme agitation


Symptoms of GHB Withdrawal

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Key:Mild = +Moderate = ++ Severe = +++


Treatment of adverse GHB effects

  • Extended delirium

  • Extreme cognitive dysfunction and amnesia

  • Medical monitoring needed

  • Response to treatment with standard medications is highly variable and potentially dangerous

  • Only treatment is often supportive care


Ketamine


Ketamine

  •  Extensive use in Vietnam War

  •  Current use on animals & humans

  •  Behavioral Analog of PCP

  •  1/4th the strength of PCP

  •  Medically in liquid injectable form


Ketamine

  • Can be heated in oven/microwave to make powder

  • Powder looks like cocaine/methamphetamine


Ketamine – “Special K”

  • Snorted or smoked

  • Dissociative effects called a “K-hole” – your brain is active but your body isn’t, “like you’re in a tunnel, your hear echoes, you’re in a semi-conscious state”

  • Used at rave/dance club scene, not as popular as in past

  • “like living inside a big cotton ball,” “everything is in slow motion”

  • flashbacks


Ketamine

  • Central nervous system depressant

  • Rapid acting-acting dissociative anesthetic

  • Sedative-hypnotic, analgesic and hallucinogenic properties

  • Structurally similar to PCP

  • N-methyl-D-aspartate (NMDA) antagonist


Ketamine

Sources & Distribution

 Diversion

 Theft

 Mexico


Ketamine

  • Administration: injected, intranasal, oral

  • 10 ml vials provide 5 illicit doses

  • Sell for $20 a dosage unit

  • Rapid onset of effects

  • Duration of effects 4-6 hours


Ketamine

Street Names

 K  Vitamin K

 Ket  KitKat

 Special K Super Acid

 K-Land K-Hole

 K-Head Super K


Ketamine

Dose

  • DoseOnsetDuration

  • IM25-125mg1-5 min’s45 min’s-3 hrs

  • Oral50-450mg5-20 min’s1.5 hrs

  • Nasal25-150mg5-15 min’s10-30 min’s


Ketamine

  • Muscle spasm

  • Blurred vision

  • Dizziness

  • Slurred speech

  • Visual “flashbacks”

  • Psychological effects

  • Tolerance


Street Development

Common Ketamine Impairment

 slow slurred speech

 intoxicated like ETOH

 impaired attention

 difficulty concentrating

 disoriented

 bloodshot /watery eyes


Nitrous Oxide


Nitrous Oxide

  • Large canisters stolen from dentist or medical supply house

  • Medium canisters from performance vehicle shops

  • Little canisters from kitchen stores for whipped cream makers


Nitrous Oxide

Whippets, “cracker” & balloon

Regular whipped cream


s

Onset & Duration of Effects

  • Onset

     Immediate

  • Duration

  •  5 minutes max


Nitrous Oxide

Common Inhalant Impairment

 depressed  slow slurred speech

 impaired attention  intoxicated like ETOH

 sleep-ish  difficulty concentrating

 chemical odor  disoriented

 droopy eyelids  bloodshot /watery eyes


The New Ones

2C-B

DXM


The New Ones

2C-B

4-Bromo-2,5-dimethoxyphenethylamine

  • Originally synthesized in 1974

  • White powder pressed into tablets or gel caps.

  • Enactogen (literally “touching within”)


2C-B

The Effects

  • Lower doses

    • Feeling in touch with themselves and emotions

    • Erotic feelings

    • Being “in ones body”


2C-B

  • Higher Doses

    • Visual effects

      • Trails

      • Geometric patterns

      • Breathing objects

      • See the music

    • Nausea, trembling, nervousness

  • Very dose sensitive—a few miligrams can produces significantly more effect.

  • No known deaths—but safety not known

The Effects


The New Ones

Dextromethorphan

DXM

Robo

Skittles

CCC

Tripple Cs

DexTussin

Vitamin D


Dextromethorphan

Poison Control Center Calls

  • According to Partnership for a Drug-Free America, 10 percent of teens (2.4 million) have intentionally abused cough medication to get high.


Dextromethorphan

  • Clinical Dose

    • 15-30 mg every 6-8 hours

    • 60 mg every 12 hours for extended release

  • Abuse Doses

    • Often as high as 240-360 mg per administration


Dextromethorphan

  • Effects at high doses

    • LSD-like high

    • Out of body experience

    • Hallucinations

    • Vivid dreams with visions


Dextromethorphan

Consequences of Abuse

  • Sweating

  • Delusions

  • Hallucinations

  • High body temperature

  • Loss of consciousness

  • Tachycardia

  • Blurred vision

  • Confusion

  • Seizures

  • Vomiting


Rave toys


The Rave Drug Scene


Best friends ‘til the trip ends

  • Raves create an instant community

  • Offers everything a teenager wants

    - acceptance

    - attention

    - popularity

  • Fosters sexual or intimate behavior


Thomas E. Freese, Ph.D.

[email protected]

www.psattc.org

www.clubdrugs.org


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