Club Drugs

A wave of new drugs has become increasingly popular with today’s adolescents and young adults. These drugs are commonly known as club drugs, a term originating from the rave phenomenon. Raves are all-night dance parties with loud, pounding music and flashing lights stimulating vigorous dancing.

• History: Initially popular in England in the 1980s, raves are now very popular in the United States. They are often held in inconspicuous places such as warehouses and are frequently announced with short notice. Unique to the rave experience, a stimulatory barrage—frequently augmented by mind-altering drugs—overloads the senses.
  
  
• Trends in drug use: The rave phenomenon in the United States has increased the use of several popular drugs. In a recent study of ecstasy (a popular club drug) use in raves, 89% of rave attendees reported using ecstasy at least once, and nearly 50% reported use within the past month. This study also found that current ecstasy users were more likely than nonusers and past users to smoke marijuana and snort powder cocaine within the past 12 months.
  
  
• Emerging recreational drug use: Club drugs have reflected changing trends in the recreational use of drugs in adolescents and young adults. These new drugs are often related to parental compounds of “traditional” drugs such as amphetamines and LSD. In other cases, they reflect the availability of cheap products creatively made from common items. As new recreational drugs emerge, users must be well informed of their associated risks. Unfortunately, many young drug users are obtaining this critical information from Internet sites that often provide incorrect and misleading information. In order to provide accurate information about commonly abused club drugs, professionally written summaries should be available to caregivers, adolescents, and young adults.
  
  
• Frequency of use: Club drugs are not only popular in raves but are often used in other social settings frequented by adolescents and young adults. In a hearing before the Senate Caucus on International Drug Control, the director of the National Institute of Drug Abuse reported an increase in the use of club drugs, especially ecstasy, among those older than 12 years. Those reporting use of club drugs increased from 5.1 million in 1999 to 6.5 million in 2000. Emergency department visits related to the drug gamma-hydroxybutyric acid (GHB), also known as the "date-rape" drug, have also increased dramatically (from 56 cases in 1994 to 4,969 cases in 2000).
  
  
• Importance of education: As the use of these new drugs increases, it becomes increasingly important to educate young people and their parents and guardians about the risks associated with club drug use.
  
  
  • Internet sites can be misleading, and some people are using these sites for information. One site (DanceSafe) tries to educate nonaddicted users to the risks of club drugs. It offers free testing of tablets submitted by mail and sells home testing kits to analyze the content of pills. The site even goes so far as to compare the risks of drugs to other activities. It states, for example, that ecstasy and GHB are less risky than giving birth, motor sports, or water sports. Sites like this imply that club drugs are nonaddicting and not significantly risky. This is simply untrue.
    
    
  • The medical literature reports that club drugs can be addictive and put users at risk for long-term consequences, including death.

Methamphetamine, also known as crystal, meth, crystal meth, ice, tina, and crank, is an amphetamine derivative with similar stimulant properties. Ice began as a major drug problem in Japan. It first appeared in Hawaii and California in the mid 1980s and has now become one of the top illicit drugs in the West and Midwest.

• What it looks like: Methamphetamine powder can be inhaled, injected, or ingested. The inhaled or ingested powder eliminates use of a needle, is longer lasting, and is often odorless, colorless, and tasteless. Crystal, also known as crank, meth, or crystal meth on the street, is a white or yellow product easily created in amateur laboratories. Many illicit chemists have used lead acetate as a substrate for its production, which can cause severe lead poisoning. Methamphetamine can be injected for an intense high, or it can be snorted.



• What it does: After the initial stimulating rush, a state of high agitation typically ensues, which may lead to violent and dangerous behavior. “Tweaking” is the term used to describe this agitated and often psychotic state. During this time, users may experience delusions, hallucinations, and paranoia and are at the greatest danger to themselves and others. Some of the warning signs of stimulant addiction include the following:
  
  
  • Irritability, nervousness
  
  
  
  • Wide mood swings, depression
  
  
  
  • Unreasonable fear, suspicion
  
  
  
  • Significant weight loss
  
  
  
  • Irregular sleep pattern
  
  
  
  • Clogged, runny nose
  
  
  
  • Neglect of work and studies
  
  
  
  • Withdrawal from family
  
  
  
  • Change in friends
  
  
  
  • Loss of money


• Harmful effects: Methamphetamine highs can last up to 20 hours; heavy users may stay awake for several days. Additional risks include heart attacks, strokes, weight loss, malnutrition, fluid buildup in the lungs, and death. Methamphetamine is a highly addictive drug. It can damage nerve cells, thus causing mental impairments. Withdrawal results in abdominal cramps, gastroenteritis, headache, lethargy, breathing troubles, increased appetite, and profound depression (occasionally ending in suicide).

Ecstasy is the street name for the hallucinogenic methamphetamine derivative methylenedioxymethamphetamine (MDMA). First used in psychiatric patients, it became a popular recreational drug because of its hallucinogenic effects. Ecstasy is also known as X, E, XTC, Adam, M&M, bean, roll, clarity, and essence. It gained popularity in the 1980s and can now be purchased on the street alongside cocaine and heroin.

• What it looks like: Ecstasy is usually taken in capsule or tablet form, although it can also be crushed into a powder and injected, snorted, or smoked. The tablets often come imprinted with popular logos such as Mercedes, Gucci, Nike, Versace, Rolls Royce, Golden Arches, and even Teletubbies.
  
  
• What it does: Ecstasy is a popular club drug because of its stimulant properties. Stimulants act on the body by constricting blood flow in the veins and arteries, increasing heart rate and blood pressure, eye pupil dilation, and sweating. The effects of the drug begin 15-60 minutes after ingestion and last 1-6 hours. This enables users to dance vigorously for long periods. Ecstasy also enhances feelings of emotional closeness (leading to the nickname "love drug") combined with a sense that everything will be all right.
  
  
• Harmful effects: Ecstasy increases a chemical in the body known as catecholamine. This chemical causes blood vessel constriction and increases heart rate, leading to dehydration, high blood pressure, and severe rises in body temperature. It can cause heart attacks, heart failure, strokes, and kidney failure. Death following chronic ecstasy use has been reported. Early deaths are most often due to dehydration that leads to heart, kidney, and liver failure. Later deaths most commonly result from seizures and a condition that causes abnormal chemistries in the blood.

  Ecstasy also elevates serotonin levels in the brain, thus causing hallucinations, decreasing appetite, and increasing body temperature. Ecstasy has been shown to damage brain cells, specifically neurons releasing serotonin. "Club kids" often chew on pacifiers to counteract bruxism, or teeth grinding, a common side effect of ecstasy. Chronic use may also lead to chronic mood instability, cognitive impairment, increased impulsivity, or psychosis. Withdrawal symptoms have not been reported.

Ephedrine: Ephedrine is a stimulant similar to amphetamine and is found naturally in the Chinese herbal medicine "ma-huang" and in "Mormon’s tea." College students and truck drivers use it for its stimulant effect. Incorrectly viewed as a safe alternative to amphetamines, this "herbal ecstasy" has been associated with strokes and deaths in adolescents.

Ritalin: Ritalin (generic name, methylphenidate) is a central nervous system stimulant known on the street as vitamin R, R-ball, and skippy. This drug is used to manage attention-deficit/hyperactivity disorder (ADHD). Stimulants are the primary drugs used in treatment of this disorder and are effective 90% of the time. In the 1990s, the prevalence of methylphenidate use increased by 250% compared with the prior decade.

• What it looks like: Ritalin is a very difficult drug to make on the street, so users get Ritalin by taking prescriptions for medication written for others. Available in 5-, 10-, and 20-mg immediate-release tablets, the effects of Ritalin last up to 4 hours. Ritalin 20-mg, sustained-release tablets and Concerta (generic name, methylphenidate) 18-, 36-, and 54-mg extended-release tablets are used illegally on the street and sell for about $5. The legitimate wholesale price is about $0.28 to $1.03 per tablet.
  
  
• What it does: When used as prescribed, Ritalin reduces hyperactivity, impulsivity, and inattentiveness. On the street, the drug is used by crushing the tablet and snorting the powder through the nose or by crushing the tablets and dissolving the powder in water before injecting it. Both routes produce euphoria similar to that of cocaine. It is usually taken orally to stay awake.
  
  
• Harmful effects: These include palpitations, hallucinations, paranoia, fainting, agitation, dizziness, seizures, tremors, fever, sweating, chest pain and irregular heartbeats, liver dysfunction, and death. Chronic use can result in withdrawal, which produces symptoms such as lethargy, paranoia, apathy, and depression. These symptoms are similar to those of amphetamine (speed) withdrawal.

Phencyclidine (PCP): PCP is also known as angel dust, elephant tranquilizer, crystal, crystal joints (CJs), TAC, hog, and the sheets. It was first used in the 1950s as a general anesthetic with rapid onset but few side effects. It was rapidly discontinued in the mid 1960s because it created problems such as losing contact with reality or depression for people after surgery. By the late 1960s, it was solely used as a veterinary tranquilizer.

PCP abuse started in San Francisco, where the drug was known as the Peace Pill. PCP abuse first became widespread during the 1970s. The drug is easy and inexpensive to make and is often sold as other drugs, such as psilocybin, cocaine, amphetamine, LSD, and synthetic THC (marijuana). This has added to its wide consumption.

• What it looks like: Phencyclidine is available as white powder, liquid, tablets, leaf mixtures, and rock crystal forms. It is readily absorbed in water and alcohol. It can be smoked, inhaled, ingested, and injected. Leaf mixtures are made by sprinkling powder on tobacco, marijuana, mint, or parsley. Menthol cigarettes dipped into liquid PCP are known as supercools. Other names of cigarette PCP mixtures are hydro, dip, wet, and fry.
  
  
• What it does: PCP produces a dissociative state or an "out-of-body” experience. It produces symptoms similar to ketamine. The effects are felt most quickly with intravenous use (within minutes) and usually last for 4-6 hours. PCP crosses into the brain to produce dissociative symptoms, amnesia, delirium, disordered thought processes, frequent loss of ideas, paranoia, apathy, depersonalization, illusions, and delusions.
  
  
• Harmful effects: In large overdoses, symptoms can last from 24-48 hours. The dissociation can resemble schizophrenia. An overdose can produce high blood pressure, hostility, and alterations of body images. These unintentional actions have resulted in people jumping from heights. Neurologic signs, such as uncontrolled eye movements, inability to maintain balance, and difficulty speaking, may also occur. Users may lose consciousness (pass out) with large doses.

Ketamine: Ketamine, also known as special K, K, vitamin K, and fort dodge, is a derivative of PCP (a powerful psychedelic drug) that has become increasingly popular. Although more difficult to produce than PCP, users can obtain large, inexpensive quantities from veterinary pharmacies in Mexico. Ketamine is commonly used in hospitals for sedation and pain relief.

• What it looks like: Ketamine is abused in clubs and other social situations. Most often, ketamine is inhaled, but it may also be injected into muscle or fat just below the skin or placed into the rectum. It has also been used to ease the crash associated with cocaine or amphetamine binges.
  
  
• What it does: Ketamine increases blood pressure, heart rate, muscle tone, and salivation. The clinical effects begin within minutes and last up to an hour. Overdose, which is often referred to as falling into a "K hole," is common. Overdose is characterized by severe brain-body dissociation, or inability to sense what the environment is really like, and vomiting, restlessness, and tiredness. Ketamine can also produce an emergence reaction resulting in nightmares, floating sensation, visual and hearing disturbances, out-of-body experiences, agitation, and confusion that last up to a day after drug use. During this time, users are not necessarily asleep and usually remember the event.
  
  
• Harmful effects: Although the long-term effects of ketamine abuse have not been well studied, it is suggested that out-of-body experiences may recur even without additional use of the drug, and psychosis (severe mental instability) from chronic use may occur.

Gamma-hydroxybutyric acid, or GHB, is a hypnotic depressant known on the street by several names: easy lay, Georgia home boy, liquid X, liquid ecstasy, liquid E, grievous body harm, Gib, G-riffic, natural sleep-500, gamma-oh, cherry meth, scoop, soap, salty water, organic Quaalude, fantasy, sodium oxybate, somatomax, and gamma hydrate. GHB is perhaps best known as the date-rape drug.

• What it looks like: GHB usually comes in a liquid form that can be mixed with other liquids. Recipes for home synthesis are available on the Internet. 3-butyrolactone and 1,4 butanediol are derivatives of GHB that are converted to GHB after ingestion. They are often purchased by body builders at health food stores for their purported muscle-building and fat-burning qualities. GHB is less commonly available in the capsule form.
  
  
• What it does: GHB is a depressant similar to gamma-aminobutyric acid. Its effects range from drowsiness, forgetfulness, and loss of muscle tone to seizurelike activity, slowed heartbeat and breathing, and coma. The coma lasts 1-2 hours, with full recovery usually occurring by 8 hours. In the date-rape scenario, it is often slipped into an unwitting victim’s drink. By January 2000, the US Drug Enforcement Agency had reported 60 deaths associated with GHB use. High school kids are using this as an alternative to alcohol. It leaves no odor for parents to detect, and the effects are gone by the time users return home from a night out.
  
  
• Harmful effects: Effects of the drug begin 15-60 minutes after use and typically last up to 6 hours. It can be detected in the urine up to 12 hours after ingestion. Tolerance (progressive decreased susceptibility to a drug's effects), dependence (compulsion to take a drug to experience its psychic effects or to avoid the discomfort of its absence), and withdrawal reactions have been reported with GHB use. Respiratory depression can be severe enough to require life support on a ventilator or breathing machine until the drug effects wear off.

Rohypnol (generic name, flunitrazepam) a potent benzodiazepine (a class of tranquilizing agents), is known as Mexican Valium, circles, roofies, la rocha, roche, R2, rope, and forget-me pill. It is available in more than 60 countries in Europe and Latin America, where its legitimate use includes preoperative anesthesia. This drug is not available in North America for sale or prescription. It is usually brought into the United States by mail. Florida, California, and Texas are the states that have the most confiscations of rohypnol.

• What it looks like: The pills usually include a single score, the Roche imprint, and "1;" or "2;" to denote the tablet strength. The tablets are usually 1 or 2 mg in strength and are relatively cheap at only $5 per pill. Flunitrazepam is 10 times more potent than diazepam (the generic name for Valium) and is thus considered a cheap high. Rohypnol is odorless and colorless, making it easy to slip into someone’s drink. Rohypnol has been associated with date rape.
  
  
• What it does: Rohypnol in low doses is a sedative and muscle relaxant. In higher doses, it can cause lack of muscle control, amnesia, loss of inhibitions, and loss of consciousness. The effects are usually worsened with alcohol. Sedation occurs within 30 minutes after ingestion, with peak effects at 2 hours. As little as 1 mg can impair an individual for 8-12 hours.
  
  
• Harmful effects: Adverse effects include low blood pressure, dizziness, confusion, visual disturbances, inability to urinate fully, and, in some users, aggressive behavior. Dependence on flunitrazepam can occur. Withdrawal produces symptoms such as headache, tension, extreme anxiety, restlessness, muscle pain, light sensitivity, numbness and tingling of arms and legs, and even seizures.
  
  
• Detection: Benzodiazepines are easily detectable on most urine drug screens. However, flunitrazepam is used in such small doses and is so rapidly metabolized that it is not detected on standard drug screens, although it can be detected by specialized laboratories.

Inhalant abuse is also increasingly popular in adolescents and young adults. An inhalant is a vapor you breathe in. Of first-time inhalant users in 1998, 62% were aged 12-17 years. Inhalants may be liquid or gases.

• Nitrous oxide: This is an inhalant used in whipped cream chargers and dispensed into balloons. Known as whippets, abusers inhale nitrous air through the balloon. Nitrous oxide has anesthetic effects and may give a high from breathing the low oxygen content in the balloon. Sudden death has been reported from breathing air with low oxygen content. Other complications include air bubbles in the lungs and chest and rupture of the eardrums. Chronic abusers may develop nerve damage.
  
  
• Hydrocarbons: Inhalants are often ingredients in household products such as paint cans and air fresheners. Hydrocarbons can be abused by huffing, bagging, or sniffing. Huffing involves inhaling vapors from a cloth soaked in hydrocarbons. Bagging is inhaling a hydrocarbon that was sprayed into a bag. Finally, sniffing is direct inhalation of the hydrocarbon from its source.
  
  
  • Hydrocarbons commonly produce euphoria, drunkenness, sedation, and low brain oxygen levels. They can cause brain damage as seen in abuse of toluene, a cheap inhalant that also causes muscle damage and dangerously low potassium levels.
    
    
  • Inhalants have also been associated with the sudden death. This results from a startle reaction in which the heart becomes excessively sensitive to adrenaline because of hydrocarbon inhalant use.

Chloral hydrate: A sedative, chloral hydrate can be swallowed in the liquid or capsule form or inserted into the rectum. The combination of chloral hydrate and alcohol, known as a Mickey Finn, produces rapid loss of consciousness. This action of placing chloral hydrate unknowingly into an alcoholic beverage is referred to as "slipping a Mickey." In addition to sedative brain effects, chloral hydrate also lowers a person's ability to breathe, irritates the gastrointestinal tract, and interrupts the normal beating of the heart. Mild use is similar to alcohol intoxication (drowsiness and unsteadiness). Users often have a pearlike odor on their breath. With increased use, chloral hydrate can cause death, usually from heart disturbances.

Dextromethorphan: An over-the-counter cough suppressant, dextromethorphan has gained popularity as a drug of abuse because of its structural similarity to PCP and morphine derivatives. It is also known as DM, Robo, and Robo shots. Dextromethorphan is a depressant that can produce a high with hallucinations similar to those of PCP at larger doses. Almost two 4-oz bottles of over-the-counter cough suppressant must be ingested to reach these doses. Nausea and vomiting often prevent drinking large amounts. Pure forms are also available over the Internet.

|Web Links|

For more information: Authoritative, reliable information on club drugs can be found on the Internet. The following are just a few of the many Web sites that offer such information:

• National Criminal Justice Reference Service

• National Institute on Drug Abuse (NIDA) 

• Office of National Drug Control Policy, Club Drugs 

Media file 1: MDMA (ecstasy) and brain changes. This image shows the brain scans of a person who has never used MDMA (top) compared with scans of a person who used MDMA for an extended period of time up until 3 weeks before the images were taken. Specifically, the scans show the brain's ability to transport a neurotransmitter called serotonin from the synapse back into the releasing neuron (the brighter colors). Serotonin is fundamental to the brain's ability to handle information and express emotion. Such findings are leading researchers to conclude that an ecstasy user may be at risk of long-term, perhaps permanent, problems with learning and memory. Image courtesy of the National Institute of Drug Abuse (NIDA).

Media type:  MRI

Media file 2: Long-term effects of drug abuse. This brain scan shows that once you become addicted to a drug like cocaine, your brain is affected (and clearly changed) for a long time. The yellow shows a lot of brain activity in a normal person. Measured 10 days after using cocaine, a cocaine addict's brain shows much less normal activity. For this same person, even after 100 days without using cocaine, the brain was still not back to a normal level of functioning. Scientists are concerned that areas in the brain may never fully recover from drug abuse and addiction. Image courtesy of the National Institute of Drug Abuse (NIDA).

Media type:  MRI

Media file 3: Long-term effects of ecstasy. This image shows sections taken from the neocortex (part of the brain) of monkeys that were given ecstasy twice a day for 4 days (control monkeys were given saline). The section on the left, taken from the brain of a control monkey who was not given ecstasy, shows the presence of a high level of serotonin. The middle section shows a section from a monkey 2 weeks after receiving ecstasy. Most of the serotonin is gone. The section on the right shows a section from a monkey 7 years after receiving ecstasy. Although there has been some recovery of serotonin, the brain has still not returned to normal. Ecstasy interacts with specific targets in the brain. After repeated or long-term use, the neurons in the brain may not communicate with each other and might affect a user's mood, behavior, and memory. Image courtesy of the National Institute of Drug Abuse (NIDA).

Media type:  Image

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Author: Douglas C Finefrock, DO, Staff Physician, Department of Emergency Medicine, Albert Einstein College of Medicine, Beth Israel Medical Center.

Coauthor(s): Mai Kim Lai, MD, Staff Physician, Department of Emergency Medicine, Sparrow Hospital, Michigan State University College of Human Medicine; Karen Tonya Mason, MD, Director of Medical Student Education, Department of Emergency Medicine, Beth Israel Medical Center.

Editors: James E Keany, MD, FACEP, Director of Emergency Medical Education, Department of Emergency Medicine, Mission Hospital Regional Medical Center and Children's Hospital at Miss; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.