club drugs: understanding what they are, why people use them
TRANSCRIPT
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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
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The Club Drugs
• THE BIG ONES -• 3,4
methylenedioxymethamphetamine (Ecstasy)
• Gamma Hydroxy Butyrate (GHB)• Ketamine• Nitrous Oxide
• SOME NEW ONES• 2C-B• DXM
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methylenedioxymethamphetamine
“MDMA”, “X”, “XTC”, “Adam”
methylenedioxymethamphetamine
“MDMA”, “X”, “XTC”, “Adam”
Stimulant and hallucinogen related to methamphetamine – chronic abuse may produce
long-lasting neurotoxic effects in the brain; increases heart rate and body temperature, has contributed to heart and kidney failure; masks
sense of thirst
Stimulant and hallucinogen related to methamphetamine – chronic abuse may produce
long-lasting neurotoxic effects in the brain; increases heart rate and body temperature, has contributed to heart and kidney failure; masks
sense of thirst
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MDMA
O
O NHCH3
CH3
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Ecstacy Tabs
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Ecstasy
• MDMA technically 3,4 - Methylenedioxymethamphetamine
• Hallucinogenic amphetamine• Releases serotonin and blocks reuptake• Dopamine and adrenergic effects
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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
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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
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Percentage of Seniors Reporting Ecstasy as ‘Fairly Easy’ or ‘Very
Easy’ to get
0
5
10
15
20
25
30
35
40
45
1991 1992 1993 1994 1995 1996 1997 1998 1999
Percent
Source: Monitoring the Future Study, 1999 -- NIDA
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Ecstasy Rates by Grade 2003-2005
SOURCE: Monitoring the Future Study, 2005.
0
2
4
6
8
10
12
14
'96 '97 '98 '99 '00 '01 0'2 '03 '04 '05
8th
10th
12th
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Poison Control Center Calls for Major Substances of Abuse:
2000-2005
0
20
40
60
80
100
120
2000 2001 2002 2003 2004 2005
Tota
l Num
ber
of C
alls
Cocaine Heroin LSD PCP Meth/Amph GHB Ecstasy
SOURCE: California Poison Control System, 2006.
Los Angeles County
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Ecstacy Tablets
Anatomy of a Tab
different sizes & shapes
Typical X is 300 mg tab
50-150 mg MDMA (maybe less)
coloring
binders
coatings
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MDMA Packaging• Tootsie rolls are
softened & X hidden inside-- “Doing rolls” or “Rolling”
• Skittles--X mixed in• Pez containers--they fit
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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.
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Ecstacy
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“)
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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
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Under the Influence
dilated pupils high temp
elevated pulse insomnia
hyperactive muscle rigidity
grinding teeth sweating
increased sensual perceptions
hallucinations rare
Ecstacy
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Dilated Pupils
Ecstacy
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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
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Long-term effects
• Neurotoxicity• Damage to neurons containing
seratonin• Abnormalities in brain
morphology• Short-term memory
impairment
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BRAIN CHANGES of Ecstasy users as well as people who abstain. Ecstasy users have far less serotonin activity (dark areas). May be permanent.
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Effects of MDMA on Serotonin Transporters
The Johns Hopkins Medical InstitutionsThe Johns Hopkins Medical Institutions
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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
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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
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Most significant acute adverse effects• Hyperthermia
• Seizures• Disseminated intravascular
coagulation• Renal and liver impairment• Rhabdomyolysis
• Hyponatraemia• Confusion• Reduced consciousness• Seizures or convulsions
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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
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Psychological effects• Euphoria• Increased energy• Feeling of closeness• Depression• Increased restlessness• Increased anxiety• Decreased motivation• Anhedonia
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Psychiatric sequelae
• Depression• Panic disorders• Flashbacks• Delusions
Risk is greatest when used repeatedly and in conjunction with other drugs
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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)
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Ecstasy users had poorer performance in three general intelligence tests
05
10
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logical thinking strategicplanning
generalknowledge
MDMAmarijuananon-drug
Journal of Neurology, Neurosurgery, and Psychiatry 2000; 68:719-725
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Ecstasy users had poorer short-term memory performance than non-drug
users
0123456789
10
MDMA No Drug Use
MDMANo Drug Use
Journal of Neurology, Neurosurgery, and Psychiatry 2000; 68:719-725
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“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
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Street Development
Gamma Hydroxy Butyrate (GHB)
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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
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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
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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
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GHB Users- Rave/club crowd
- Gay community
- Exotic dancers/ strippers
- Bodybuilders
- Rapists
- Individuals subject to random or mandatory drug testing
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Gamma Hydroxy Butyrate (GHB)
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)
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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
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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
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Analogs of GHBBlue Nitro, Renewtrient, Revivarant, Remforce, Firewater Serenity, FX, Weight Belt Cleaner, Enliven, Biosul
- 1, 4 butanediol (BD or BDO)
- sold legally as a floor stripper
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GHB Indicators
• Information not collected in standardized measures
• ER Mentions: • 1994 = 55 • 1999 = 2973
• 32% of calls to Boston Poison Control involve GHB
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Common Depressant Impairment
depressed slow slurred speech
impaired attention intoxicated like ETOH
sleep-ish difficulty concentrating
under-active disoriented
droopy eyelids bloodshot /watery eyes
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GHB/GBL Analogs and Reported Uses
• Gamma-Butylactone
• 2(3H) Furanone di-hydro
• 1,4 Butanediol
• Sodium oxybate
• Improve sleep• Insomnia• Dancing• Avoid drug testing• Antidepressant• Antianxiety• Socialize• Weight lifting
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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%
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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 less 42.9%
• How many times per day• Once 28.6%• 2-3 times 42.9%• 4 or more 28.6%
• How much do you use at a time?• < 1 capful 9.5%• 1-3 capfuls 73.8%• > 3 capfuls 14.3%• Other 2.4%
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Subjective Effects of GHB Reported by > 50% of participants
• Euphoria• Increased
sexuality• Wellbeing• Relaxation• Talkative• Tranquility• Drowsiness
• Optimism• Increased
energy• Giddiness• Increased
sensitivity to sound
• Silliness• Sweaty• Loss of
consciousness
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Subjective Effects After GHB Use
• 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
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GHB Abuse
Tolerance Down regulation of inhibitory GABA-A, GABA-B, GHB receptors
Dysinhibition of Excitatory Neurotransmitters (Glutamate, NMDA, Norepinephrine, Dopamine)
Decreased GHB Consumption
Anxiety Restlessness Insomnia Tremor Confusion Delirium Hallucinations Tachycardia Hypertension Nausea Vomiting Diaphoresis
Withdrawal
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Loss ofConsciousness
Amnesia
Overdose
Alcohol Use
Other Drug Use
Confusion
Suicide
Sleep
Withdrawal
FACTORS ASSOCIATED WITH GHB OVERDOSE
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After GHB Withdrawal –Clinical Concerns
Severity of “protracted withdrawal” associated with severity acute withdrawal
• Depression• Anhedonia - negative symptoms• Panic attacks• Tremor • Paresthesia• Overdose
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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
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Symptoms of GHB WithdrawalSymptoms Early (1-24 hrs)
Progressive (1-6 days)
Episodic (7-14 days)
Anxiety/Restlessness
Insomnia
Tremor
Confusion
Delirium
Auditory/Visual Hallucinations
Tachycardia
Hypertension
Nausea
Vomiting
Sweating
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Key: Mild = + Moderate = ++ Severe = +++
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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
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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
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• Can be heated in oven/microwave to make powder
• Powder looks like cocaine/methamphetamine
Ketamine
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Ketamine – “Special K” 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
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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
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Ketamine
Sources & Distribution
Diversion
Theft
Mexico
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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
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Ketamine
Street Names
K Vitamin K
Ket KitKat
Special K Super Acid
K-Land K-Hole
K-Head Super K
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Ketamine
Dose
Dose Onset Duration
IM 25-125mg 1-5 min’s 45 min’s-3 hrs
Oral 50-450mg 5-20 min’s 1.5 hrs
Nasal 25-150mg 5-15 min’s 10-30 min’s
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Ketamine
• Muscle spasm• Blurred vision• Dizziness• Slurred speech• Visual “flashbacks”• Psychological effects• Tolerance
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Street Development
Common Ketamine Impairment
slow slurred speech
intoxicated like ETOH
impaired attention
difficulty concentrating
disoriented
bloodshot /watery eyes
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Nitrous Oxide
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Nitrous OxideLarge canisters
stolen from dentist or medical supply house
Medium canisters from performance vehicle shops
Little canisters from kitchen stores for whipped cream makers
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Nitrous OxideWhippets,
“cracker” & balloon
Regular whipped cream
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s
Onset
Immediate
Duration
5 minutes max
Onset & Duration of Effects
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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
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The New Ones
2C-B
DXM
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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”)
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2C-B
The Effects
• Lower doses• Feeling in touch with themselves and emotions• Erotic feelings• Being “in ones body”
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2C-B
The Effects• 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
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The New Ones
DextromethorphanDXMRobo
SkittlesCCC
Tripple CsDex
TussinVitamin D
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Dextromethorphan
• According to Partnership for a Drug-Free America, 10 percent of teens (2.4 million) have intentionally abused cough medication to get high.
0
500
1000
1500
2000
2500
3000
3500
2000 2001 2002 2003
Teens All others
Poison Control Center Calls
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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
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Dextromethorphan
• Effects at high doses• LSD-like high• Out of body experience• Hallucinations• Vivid dreams with visions
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Dextromethorphan
• Sweating• Delusions• Hallucinations• High body temperature• Loss of consciousness
Consequences of Abuse
• Tachycardia• Blurred vision• Confusion• Seizures• Vomiting
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Rave toys
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The Rave Drug Scene
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Best friends ‘til the trip ends
• Raves create an instant community
• Offers everything a teenager wants- acceptance- attention- popularity
• Fosters sexual or intimate behavior