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

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

MDMA

O

O NHCH3

CH3

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

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5

10

15

20

25

30

35

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45

1991 1992 1993 1994 1995 1996 1997 1998 1999

Percent

Source: Monitoring the Future Study, 1999 -- NIDA

Ecstasy Rates by Grade 2003-2005

SOURCE: Monitoring the Future Study, 2005.

0

2

4

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'96 '97 '98 '99 '00 '01 0'2 '03 '04 '05

8th

10th

12th

Poison Control Center Calls for Major Substances of Abuse:

2000-2005

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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

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

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

Under the Influence

dilated pupils high temp

elevated pulse insomnia

hyperactive muscle rigidity

grinding teeth sweating

increased sensual perceptions

hallucinations rare

Ecstacy

Dilated Pupils

Ecstacy

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 InstitutionsThe 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

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45

logical thinking strategicplanning

generalknowledge

MDMAmarijuananon-drug

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

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

“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

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)

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 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

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

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

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 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%

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

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

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

Loss ofConsciousness

Amnesia

Overdose

Alcohol Use

Other Drug Use

Confusion

Suicide

Sleep

Withdrawal

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 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 = +++

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

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

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

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

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

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 OxideLarge canisters

stolen from dentist or medical supply house

Medium canisters from performance vehicle shops

Little canisters from kitchen stores for whipped cream makers

Nitrous OxideWhippets,

“cracker” & balloon

Regular whipped cream

s

Onset

Immediate

Duration

5 minutes max

Onset & Duration of Effects

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

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

The New Ones

DextromethorphanDXMRobo

SkittlesCCC

Tripple CsDex

TussinVitamin D

Dextromethorphan

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

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Poison Control Center Calls

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

• Sweating• Delusions• Hallucinations• High body temperature• Loss of consciousness

Consequences of Abuse

• 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.tefreese@ix.netcom.com

www.psattc.org

www.clubdrugs.org