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CLUB DRUGS Nothing to Rave About

CLUB DRUGS Nothing to Rave About. Cynthia C. Haith, M.D. Department of Pediatrics May 12, 2004. Goals. To familiarize you with various aspects of rave culture To alert you to the dangers associated with club drugs To illustrate the role of the Internet

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CLUB DRUGS Nothing to Rave About

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  1. CLUB DRUGS Nothing to Rave About Cynthia C. Haith, M.D. Department of Pediatrics May 12, 2004

  2. Goals • To familiarize you with various aspects of rave culture • To alert you to the dangers associated with club drugs • To illustrate the role of the Internet • To help you better educate your patients and their families and hopefully prevent future use of club drugs

  3. RAVES • All-night dance parties • Characterized by loud, pulsating, techno music and visual effects with strobe and laser lights

  4. RAVES • Originated in England in the late 1980s • Attended largely by adolescents and promoted by a small group of disc jockeys • Initially were underground, often held in large warehouses or stadiums • Logistical information sent out at the last minute; spread by word of mouth • Associated with illicit use of drugs and alcohol

  5. RAVES • British authorities became aware and ultimately made them illegal • By the late 1980s rave culture then migrated to the United States • By the mid-1990s explosive growth of dance club scene popularized by youth

  6. RAVES • Now have become more mainstream and commercialized • Concert promoters sponsor raves (legally) at prominent venues in most major cities • Advertised via flyers, posters, telephone, radio, and the Internet • Many events advertised as “alcohol free”

  7. Raves and Drugs • Ravers’ Motto: • P.L.U.R.Message of peace, love, unity, and respect • Photo below depicts a rave “enhanced” by Ectasy

  8. Raves and Drugs • World Wide Internet and dance club growth paralleled the rise of club drug abuse • Raves promoted as a “safe event” because no alcohol is sold • However, alcohol is NOT the drug of choice • Raves typically last all night • Drugs help participants stay up all night and come down at dawn • Drugs used to maintain energy levels and facilitate prolonged dancing

  9. Raves and Drugs • Serve to intensify the sensory experience of the lights and the music • Lowers inhibitsions • Helps participants dismiss classic social barriers and connect to peers regardless of sex, ethnic background or social class

  10. Raves and Drugs • Common misconception - these drugs provide a “safe high” • Relatively inexpensive • Readily available

  11. Rave Paraphernalia • Surgical Masks • Vicks Vapor Rub and Menthol nasal inhalers • Glow Sticks • Skittles, M&M’s and other candies Lollipops and Pacifiers

  12. Common Club Drugs • MDMA (Ecstasy) • Gamma-hydroxybutyrate (GHB) • Ketamine • Rohypnol • Metamphetamine • Lysergic acid diethylamide (LSD)

  13. Club Drugs • Club Drugs are not safe • 2 mechanisms contributing to club drug toxicity: • “Cafeteria” Drug Use • adolescents sample whatever drugs are available for sale at a venue • Adulterated or diluted drugs • Adulterated Drugs • May contain other substances with little or none of the intended drug • Dilution attenuates the effect • Forces users to use repeated doses to achieve desired effect - “stacking” • Successive redosing can lead to OD and toxicity

  14. Epidemiology • Monitoring the Future Study • Implemented in 1975 • Funded by National Institute of Drug Abuse (NIDA) and conducted by the University of Michigan’s Institute for Social Research • An ongoing study of the behaviors, attitudes, and values of American secondary school students, college students, and young adults. • Surveys 50,000 8th, 10th and 12th graders • Collects data on past month, past year, and lifetime drug use

  15. Epidemiology • According to the 29th annual study conducted in 2003 • Percentages of illicit drug use has declined among 8th and 10th graders • Ecstasy use has also declined in each grade • 8th graders: from 2.9 to 2.1 percent • 10th graders: from 4.9 to 3.0 percent • 12th graders: from 7.4 to 4.5 percent • However according to the DEA • Ecstasy use is on the rise in NC • LSD use has increased in Charlotte

  16. Epidemiology

  17. Epidemiology

  18. Epidemiology • Drug Abuse Warning Network (DAWN) • DAWN is a national surveillance system operated by the federal government that monitors trends in drug-related emergency department visits and deaths.

  19. Epidemiology • According to DAWN • Most frequent ED mentions of club drugs • Methamphetamine, MDMA, GHB, LSD, Ketamine • Most ED visits involving club drugs also involve other drugs • Particularly alcohol and marijuana

  20. Epidemiology

  21. MDMA (Ecstasy) • 3,4-Methylenedioxymethamphetamine • Structurally resembles both the stimulant amphetamine and the hallucinogen mescaline • Street names • Ecstasy, Adam, Bean, XTC, E, X, Hug Drug, Lovers’ Speed

  22. History of MDMA • Synthesized in 1912 in Germany by Merck and patented in 1914 as an appetite suppressant • Secretly studied by the U.S. military/CIA in the 1950s as a possible truth serum • Became popular in the 1970s among psychotherapists as an adjunct to therapy • enhanced communication and improved self-esteem

  23. History of MDMA • During this time (late 1970s) MDMA became available on the streets • By the mid-1980s it was becoming more widely abused • In 1985 the Drug Enforcement Agency classified MDMA a Schedule I drug • declaring it a substance with high abuse potential, no accepted medical uses, and illegal to possess

  24. MDMA • History cont. • Initial popularity faded and usage declined in the mid-1980s after it was classified as a Schedule I drug • In the 1990s MDMA abuse escalated corresponding with the growing popularity of raves

  25. MDMA • Availability • Produced primarily in Europe, smuggled to US, and sold illegally • Synthesis is relatively simple • “How-to” instructions available on Internet • Usually ingested in tablet form • can also be crushed and snorted, injected or used as suppository • Costs $0.02-$0.50 per tablet to produce • Sells for $15 to $50 per tablet in the U.S.

  26. MDMA • Tablets come in a variety of colors and are commonly imprinted with popular culture icons

  27. MDMA • Usual recreational dose is 100-150 mg • Although some users “stack” MDMA • Not standardized or regulated • Concentration can range from 0 to 200 mg • Many other drugs (adulterants) combined with MDMA and marketed as Ecstasy

  28. Methamphetamine Phencyclidine (PCP) Ketamine Methylenedioxy-ampethamine (MDA or “Love Drug”) Methylenedioxy- ethamphetamine (MDEA or “Eve”) Dextromethorphan Acetaminophen Caffeine Ephedrine/Pseudo-ephedrine Aspirin Drugs Found in “Ecstasy”

  29. MDMA • Metabolism • Demethylenation to DHMA or MDA • Partially metabolized in the liver by the CYP2D6 isoenzyme of cytochrome P-450 • 50-70% of MDMA is excreted unchanged in the urine • Pharmacokinetics • Onset of action: 20 to 40 minutes • Duration of action: 2 to 6 hours

  30. MDMA • Mechanism of Action • Indirect sympathomimetic • Acts primarily by releasing excess serotonin from presynaptic neurons - up to 80% of stores • releases dopamine and norepinephrine to a lesser extent • Inhibits reuptake of serotonin

  31. Review of Neurotransmitters • Serotonin - involved in regulation of a variety of behavioral functions • mood, anxiety, aggression, appetite, and sleep • Dopamine • motivational processes - reward and reinforcement • Norepinephrine • important roles in the processes of attention and arousal

  32. MDMA and Serotonin

  33. Why Take Ecstasy? • Referred to as an “Enactogen” • means “touching within” • Produces euphoria and a sense of well-being or inner peace • Heightens energy, empathy towards others, emotional warmth and desire to socialize

  34. Why Take Ecstasy? • Mental stimulation • Heightens sexual arousal • Enhances sensory perception • Causes sensory distortion and illusion, but not overt hallucinations

  35. Adverse Effects • Nonspecific effects • diaphoresis, mydriasis, blurred vision, nausea, dry mouth, decreased appetite and thirst • can cause sexual dysfunction in men • Cardiovascular • Tachycardia, vasoconstriction, hypertension • Muscular • Trismus (tightening of jaw muscles) and bruxism (jaw-clenching), muscle tension and spasms, muscle aches, motor tics • Neurologic • headache, tremor, ataxia

  36. Acute Complications • Toxicity not necessarily dose dependent • In one case a person attempted suicide with an overdose of Ecstasy. After taking 47 pills he had a resultant plasma MDMA level of 7.72 mcg/ml, but displayed only tachycardia and hypertension.3 • There are reports of others who have died with much lower MDMA levels from 0.05 to 1.26 mcg/ml.12

  37. Acute Complications • Hyperthermia • multifactorial • serotonergic effects on thermoregulatory center • hot rave environment • prolonged dancing ->excessive heat production • temperatures as high as 43o C (>109o F) • may lead to DIC, rhabdomyolysis, myoglobinuria, and acute renal failure • Treatment with dantrolene is controversial

  38. Acute Complications • Hyponatremia • two proposed mechanisms • SIADH - MDMA leads to increased levels of arginine vasopressin (ADH) • water intoxication - dehydration associated with massive water intake • Hepatotoxicity • proposed mechanisms • injury secondary to hyperthermia • production of hepatotoxic metabolites

  39. Acute Complications • Drug Interactions • Antiretrovirals • Reported fatality in 1996 of a HIV-positive person who had recently started taking ritanovir* • This person ingested 180 mg MDMA and the resultant blood level was 4.56 mcg/ml (higher than expected) • Ritonavir inhibits hepatic isoenzyme CYP2D6, which is required to metabolize MDMA

  40. Chronic Complications • Long-term neurotoxicity • Memory and cognitive impairment • Psychological difficulties • confusion, depression, insomnia, drug craving, anxiety and paranoia • may last days to weeks after ingestion • Animal studies have shown: • reductions in brain levels of serotonin and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) • reductions in the serotonin transporter • degeneration of serotonin terminals

  41. Chronic Complications • One study by Hatzidimitriou et al10 • demonstrated neurotoxic effects of MDMA in monkeys persisting up to 7 years after administration • there was evidence of some regrowth of axons, but that it may be abnormal and incomplete

  42. Chronic Complications

  43. Chronic Complications • Human Studies • dose-dependent decreases of 5-HIAA in CSF • PET scans have shown decreased serotonin receptor binding11

  44. Is MDMA Addictive? • Most users believe that it is not • However, it can be addictive for some • psychological dependence • With repeated dosing, tolerance develops to the desired effects • due to serotonin depletion • tolerance does not develop to the adverse effects

  45. Methamphetamine • N-methyl homolog of amphetamine • Street names • Crank, Chalk, Crystal, Meth, Ice, Glass, Fire Speed, Yaba

  46. Methamphetamine • History • Amphetamine first synthesized in 1887 • Used as a nasal decongestant (Benzedrine) and bronchial inhaler in 1930s • Supplied as stimulants for soldiers and prisoners of war in WWII • From 1950 to 1970, sporadic periods of widespread use and abuse • Controlled Substance Act of 1970 listed it as Schedule II

  47. Methamphetamine • Limited medical indications • narcolepsy • attention deficit hyperactivity disorder • short-term treatment of obesity

  48. Methamphetamine • Forms • white, odorless powder - dissolves in waterclear, • chunky crystals • small, brightly colored tablets (Yaba) • Can be injected intravenously, smoked, snorted or taken orally

  49. Methamphetamine • Primarily produced in clandestine laboratories in California and Mexico • Yaba - most often produced in Southeast Asia • Easily synthesized in home labs using OTC products - pseudoephedrine • home meth lab raided yesterday in Charlotte

  50. Methamphetamine • Injection or smoking • immediately causes a “rush” or “flash” • described as extremely pleasurable • lasts only a few minutes • Oral or intranasal use • produces euphoria - a high, but not a rush • onset 3 to 5 minutes for intranasal; 15 to 20 minutes for oral

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