An 18 year old male presents to the ED where you are working at about 3 am after being at a “rave.” The patient is staring off into space, clenching his jaw, and trying to hug the nurse as she starts an IV. The nurse has difficulty starting the IV due to patient’s dehydration. You notice his pupils are enlarged and he is tachycardic, he grabs your pen light and stares into it and moves it around in circles. His body temperature is elevated. Would you know what substance was most likely the cause of this patient’s condition?
Club drugs take their name from their association with raves, all-night dance parties typically hosted in unremarkable locations such as warehouses. Party-goers, known as “ravers” often supplement this sensory barrage with a variety of mind altering substances, hence the name “club drugs.” It is important for those in the medical profession to recognize the presentations of various drug-related syndromes in order to provide the best treatment. We also need to be able to communicate with patients about their drug use. Test your drug knowledge on the following words and phrases (answers are at the end of the article):
- Skin popping
- Foxy methoxy
- Chasing the dragon
If your response to reading over this list is a blank stare and a furrowed brow, read on. Yes, medical students need to get hip with what the kids are doing these days. Not only is it crucial for those occasions when your family and friends turn to you as the resident medical guru, it’s also on the boards!
So without further ado, let’s review the commonly abused drugs and some of their features that you may be tested on, pimped about, or just generally exposed to during your medical training.
Alcohol is one of the most commonly abused substances, and therefore one of the substances you should be the most familiar with – preferably not because you are drowning your sorrows about that last exam in a bottle of cheap whiskey. Alcohol is a CNS depressant that appears to act mainly as an agonist on GABA receptors and a blocker at NMDA receptors. It is more correctly referred to as ethanol or “EtOH” because there are other types of alcohols, including methanol (solvent alcohol), acetone (nail polish remover), and ethylene glycol (antifreeze). All these are part of the classic “MUDPILES” acronym for anion gap acidosis, because they are metabolized to ketoacids.
- One drink = 1 shot = 1 glass of wine = 1 beer, each drink should elevate the blood ethanol level by approximately 20mg/dL, and coincidentally, this is about the amount that is metabolized by the average person in one hour.
- You must be able to identify alcohol withdrawal, for two reasons: one, it often presents in hospitalized patients who have not revealed that they are dependent on alcohol, and two, it can kill you. Therefore, when a patient on the wards (or in a board question) becomes tachycardic, agitated/tremulous, diaphoretic, and hypertensive, if you are the only one on the team to think of ethanol withdrawal, you’ll look like a superstar. Classically (in a board question) the patient will have been in the hospital for about 3 days, but in reality, onset can be as early as a few hours after the last drink. Another presentation that should raise your antennae is a patient with no history of seizure disorder who has a seizure after a day or two in the hospital. These seizures do usually have a brief post-ictal state, and are often accompanied by the other manifestations of ethanol withdrawal. Ethanol levels are likely to be negligible or zero, but should be drawn.
- The big names to associate with alcohol are Wernicke and Korsakoff – a.k.a Wernicke-Korsakoff syndrome, which is a result of thiamine deficiency related to alcoholism. Wernicke’s encephalopathy is ataxia, altered mental status, and ophthalmoplegia. It can progress to Korsakoff psychosis, in which patients cannot recall events and so they create improbable stories to explain what has happened. This is called ‘confabulation’. Many a medical student has been fooled by a confabulator. Remember – if a wild tale starts sounding way too wild to be true, you might be dealing with a confabulator.
- Fun fact: ethanol is the treatment for methanol poisoning, because it competitively inhibits methanol turning into formate. “Nurse, get this man a liter of IV tequila – STAT!”
Cocaine is another one of the most dangerous drugs of abuse to look for, especially since reportedly, use of cocaine has increased significantly among college students. Cocaine can be used in a number of ways – the important thing to realize about it is that as the cocaine is purified, the “high” is shorter and the addiction potential is greater. While chewing on a coca leaf can make a user feel mildly euphoric for a few hours, smoking crack cocaine gives the user a rush before they even have time to exhale. Cocaine use results in tachycardia, but also can cause dangerous arrhythmias, and can precipitate myocardial infarction through coronary vasospasm. The mainstay of treatment is benzodiazepines.
Ecstasy (MDMA) is probably the most famous club drug, popularly used at raves and dance clubs. It came to prominence in the 1960s and 1970s when it was used as part of psychotherapy, for which it appeared useful to facilitate communication as part of relationship counseling. It is a synthetic drug that is used in pill form. The pills may be colorful and imprinted with different logos and symbols. The most common concern for side effects of ecstasy is during its use at dance parties, when users may go for many hours without drinking enough water to stay hydrated. The combination of increased temperature and dancing can cause significant dehydration. Common effects include euphoria and increased appreciation of tactile stimuli, such as in the scenario presented at the beginning of this article. Ecstasy is unlikely to kill users and usually only results in death if combined with other drugs. Treatment is symptomatic.
Methamphetamine is known on the street as “speed” or “crank” – or just “meth.” A powerful stimulant, methamphetamine increases levels of brain dopamine significantly, resulting in increased movement and enhanced mood. Although methamphetamine is classified in DEA Schedule II, it is not widely prescribed. The vast majority of methamphetamine abused in the United States today is imported illegally or made in small, covert labs stateside. The process of making methamphetamine is very dangerous, utilizing toxic chemicals with a high risk of explosion. These illicit “meth labs” endanger both the users engaged in “cooking” the meth as well as neighbors and the environment.
Methamphetamine can be taken orally, by snorting, by injection, or by smoking. Tolerance and addiction are often rapid. Symptoms of methamphetamine use include wakefulness, increased physical activity, loss of appetite, rapid heart and respiratory rates, increased blood pressure and hyperthermia. Users may experience insomnia, anxiety, confusion, tremor, convulsions, aggression, hallucinations, memory loss and severe dental problems. Treatment for methamphetamine addiction is challenging and should include cognitive-behavioral therapy to help break deeply entrenched patterns of abuse.
Mushrooms have been known for their psychoactive properties for centuries. When you hear people referring to “shrooms” as a hallucinogen, they’re generally referring to Psilocybin mushrooms, also known as “magic mushrooms”. Mushrooms that contain the compounds psilocybin or psilocin cause users to have hallucinations and feelings of euphoria that last about 6-8 hours. Contrary to popular belief, the effects are not due to the “poisonous” nature of the mushrooms. In fact, the National Institute of Occupational Safety and Health’s Registry of Toxic Effects rates psilocybin’s toxicity at 641 (with 1 being most toxic), compared to aspirin at 199 and nicotine at 21. A person would reportedly have to consume his or her own body weight in psilocybin mushrooms to take a lethal dose. Not surprisingly, then, treatment is mainly observation and supportive care until the effects wear off. Psilocybin can be much more dangerous when used with alcohol or marijuana, due to increased amounts of risky behavior. Unpleasant side effects can include nausea and vomiting.
Heroin was marketed by Bayer from 1898-1910 as a cough syrup and as a cure for morphine addiction, until the public discovered that heroin is merely an acetylated form of morphine which is not only converted to morphine as it is metabolized in the liver, but also is approximately twice as potent. This brought bad press for Bayer. Heroin is well-known as a highly addictive substance which can cause withdrawal symptoms after just a few days of use. Its classic effects include CNS/respiratory depression and miosis (pinpoint pupils). Withdrawal from heroin, referred to by patients as being “dope sick”, results in numerous unpleasant symptoms such as malaise, nausea and vomiting, diarrhea, muscle cramping and aches. You may note that your patients also begin yawning as they go into withdrawal. Withdrawal can be abruptly precipitated by the use of naloxone (Narcan), an opiate antagonist. This can have the unfortunate effect of causing the patient to go from a comatose state to an agitated, “dope sick” state which can be followed by the patient’s rapid departure against medical advice to seek more heroin. For this reason it is advisable to titrate naloxone by using small doses. It is important to note that however unhappy those in heroin withdrawal may be, withdrawal from heroin cannot kill you. Heroin is most commonly injected IV but can also be snorted or injected subcutaneously. Heroin plus cocaine injected IV is known as a ‘speedball’.
Ketamine is a dissociative anesthetic that is used in veterinary and human medicine. Classified as an NMDA receptor antagonist, ketamine induces a state known as dissociative anesthesia, in which signals from the conscious mind to other parts of the brain are blocked. Ketamine is primarily used in the induction and maintenance of general anesthesia, usually in combination with a sedative. Because it produces less respiratory depression than other anesthetics, Ketamine is useful in children and in emergency department patients with unknown medical histories. Besides its legitimate medical uses, Ketamine, or “Special K” is often used illicitly. Symptoms of Ketamine intoxication include sedation, hallucinations, a sense of bodily detachment, sensory distortions and unintelligible speech. No antidote exists and treatment is supportive.
PCP or phencyclidine is a dissociative hallucinogen that can be used either in crystalline or liquid form. In the liquid form, cigarettes or joints my be dipped in PCP then smoked. Its best known street name (though it has many) is “angel dust”. On a typical exam question, a patient will present to the emergency room with tachycardia, agitation, and potentially nystagmus or ataxia. The hallmark of phencyclidine on an exam question is that the patient will be engaging in highly violent behavior. The drug can cause behavioral disturbances as well as decreased pain sensation, the combination of these two factors increase the risk for violence.
GHB made headlines worldwide last month when it was revealed that the Chinese-made toy Aqua Dots was coated in a chemical that, once metabolized, converts into the “date rape” drug gamma-hydroxy butyrate. A massive recall and tons of publicity left many worried parents wondering, “what is this drug?”
GHB is known on the street as Grievous Bodily Harm, Georgia Home Boy or Liquid Ecstasy. It is a clear liquid that resembles water but has a slightly salty taste. Banned in the United States, GHB is nonetheless available for purchase on the internet or imported from other countries. Often sold in small bottles, GHB can be mixed with water or combined with other beverages to conceal its flavor. The ability to slip this substance into the drink of an unsuspecting victim, along with its sedative and amnestic properties have implicated GHB as a drug used in facilitated sexual assault.
The classic signs of GHB intoxication are CNS and respiratory depression, but GHB also has effects on other organ systems. Symptoms may include nystagmus, ataxia, seizures, vomiting, somnolence and aggression. Extreme CNS depression is most commonly observed in patients presenting to the ED with GHB overdose, but this CNS depression may resolve suddenly due to rebound effects from the drug. A patient may go from completely unresponsive to agitated and combative in a very short time frame.
Benzodiazepines or “benzos” are a class of prescription drugs with varying hypnotic, anxiolytic, sedative, anticonvulsant, amnestic and muscle relaxant properties. They are useful in the induction of anesthesia and the treatment of insomnia, anxiety, agitation, seizures, muscle spasms and alcohol withdrawal. Recreational users of stimulants may use benzos as a means of “coming down.”
Benzodiazepines exert their action at the GABA-A receptor in the CNS. Taken alone, benzodiazepines are considered very safe. When combined with other substances such as alcohol, serious or fatal CNS, respiratory or cardiovascular depression may occur. Symptoms of benzodiazepine intoxication include drowsiness, ataxia, confusion and vertigo.
Common benzodiazepines used in practice include alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), lorazepam (Ativan), midazolam (Versed) and temazepam (Restoril). Rohypnol (flunitrazepam) is a type of benzodiazepine that is available in Mexico and Latin America and imported illegally into the United States. Particularly insidious are its amnestic properties and its tasteless, odorless formulation. These characteristics make “roofies,” as they are popularly known, a frighteningly effective tool in drug-facilitated sexual assault. The danger of this drug contributed to its inclusion in the Drug-Induced Rape Prevention and Punishment Act of 1996.
Drugs used for date rape such as Rohypnol and GHB can only be detected within a short time of ingestion on a drug screen, so if there is any question of their use, patients must be tested as soon as possible. Standard drug screens may not capture these chemicals; practitioners should make sure to specify the need to test for these drugs if their presence is suspected. This can be challenging as part of the drugs’ effectiveness is their ability to cloud the memory of their victims, leaving doubt about the events that transpired.
Answers to quiz:
- Skin popping is the street name for injecting drugs like heroin subcutaneously instead of IV. It’s a high risk behavior for abscesses and other infections.
- Foxy methoxy’s chemical name is N,N-Diisopropyl-5-methoxytryptamine (5-MeO-DIPT) – it really rolls off the tongue, doesn’t it? Foxy is a short-acting psychedelic that can be swallowed, snorted, or smoked.
- Chasing the dragon is a phase that originated in Hong Kong, referring to inhalation of fumes while heating heroin. It is linked to the development toxic leukoencephalopathy, the pathophysiology is unknown.
- Robotripping refers to tripping by drinking Robitussin or other cough syrup to achieve a hallucinogenic amount of the chemical dextromethorphan or DXM.
- A “K hole” is a term for the dissociative effects of ketamine intoxication.
What about our patient? Have you figured out what substance this young man has ingested? From his clinical presentation, the likely answer is MDMA. The big clues are: hugging (MDMA is often referred to as the “love drug”), bruxism (clenching of the jaw – one reason that ravers are often seen sucking pacifiers), increased body temperature and dehydration. This patient has probably been rollin’ (slang for being high on MDMA). Good job!
NIDA Info Facts: Methamphetamine
E-medicine: Club Drugs
Midwest Emergency Services: GHB