"Club" Drugs 101: Substance Use and Abuse for 21st Century Clinicians
"Club" Drugs 101: Substance Use and Abuse for 21st Century Clinicians
Fifteen-year-old Michael has been your patient since he was born. He has always been healthy, and his annual well visits have been uneventful. Last week, you saw his 12-year-old sister and 11-year-old brother for their summer camp physical examinations. When you asked their mother how things have been going at home, she rolled her eyes and laughed. "Well, the younger kids have been doing great. Michael, on the other hand . . . let's just say he's become a challenge."
You think back to that conversation as you pick up his chart to see him today and think, "Michael is such a great kid. His mom must be exaggerating." Your jaw drops when you see him. The clean-cut kid you remember has disappeared. In his place is the new Michael—complete with a half-shaved head of green hair, multiple earrings in each ear, a small nose stud, and a stainless silver tongue ring. Michael seems to sense your surprise, smiles, and asks, "So what do you think???"
You somehow maintain your composure and proceed with the history and physical examination. Michael admits that he and his parents "haven't been seeing eye to eye recently" on a lot of issues. During the past year, he connected with a new group of friends. Saturday night movies and video games have been replaced by all-night clubs, where he dances to "trance" and "techno" music. Michael confides that he tells his parents that he sleeps at a friend's house on Saturday nights, while in reality, he stays at the clubs until 6 am every Sunday morning.
This gives you a perfect opportunity to ask Michael about alcohol and marijuana use. Michael laughs and answers, "No way! When I party the only thing I drink is bottled water. Alcohol and weed wear ya out. I don't do any dangerous drugs like cocaine, LSD, crack, or heroin. But I sometimes need a little something to keep me going until Sunday morning. . . ."
When you ask for clarification, Michael shakes his head and slyly says, "If you gotta ask then you just don't get it. . . ."
Like Michael, most teenagers correctly assume that their health care providers are relatively uninformed when it comes to the new generation of substance abuse. However, teenagers of all socioeconomic backgrounds have demonstrated an increase in experimentation and use of various synthetic substances designed to enhance their overall experience when attending a party known as a "rave."
A rave is an all-night dance party—usually held at a large dance club or at a rented venue (such as a warehouse). These parties attract hundreds to thousands of participants and often include special effects with lighting, lasers, smoke, professional dancers, confetti, etc. Most commonly, the DJ fills the room with trance music—so named for its unending repetition of musical phrases and rhythms.
A significant part of "rave culture" involves the availability of, and subsequent experimentation with, synthetic drugs designed to augment the trance music and the visual stimulation provided by the club.
Here I describe 4 substances that are commonly abused by teenagers as part of the rave scene: 3,4-methylenedioxymethamphetamine (MDMA, also known as "Ecstasy"), ketamine, γ-hydroxybutyrate (GHB), and methamphetamine. This review is meant to be a basic introduction to help practitioners get "up to speed" (forgive the pun) on these substances so that they can better communicate the risks involved to their adolescent patients.
MDMA is an amphetamine that acts both as a CNS stimulant and as a mild hallucinogen. It is sold on the street or in clubs as Ecstasy and may also be known by its various nicknames: "E," "X," "XTC," "Love," or "Hug Drug." Although the drug has been labeled a category 1 (illegal) drug since the 1980s, it is commonly imported from the Netherlands and Belgium, and there have been reports of increasing home production in the United States.
Ecstasy is generally sold as a pill inscribed with its maker's "brand name" (Figure 1). The tablets rarely contain pure MDMA and, like many illegal substances, they can be infused with other drugs (eg, caffeine, dextromethorphan, ephedrine, and methamphetamine) to enhance their effects. The Monitoring the Future Survey of 10th- and 12th-graders indicated that Ecstasy use dropped between 2001 and 2004 but that the lifetime prevalence of MDMA use among 12th-graders is still significant at 7.5%.1
Once Ecstasy is ingested, the brain undergoes an increase in dopaminergic, serotonergic, and norepinephrine pathway stimulation. Physically, this initially manifests as tachycardia, increased blood pressure, hyperthermia, bruxism (jaw clenching), and blurred vision. An hour after ingestion, most unpleasant effects are replaced by a sense of euphoria that can last for 3 to 4 hours. A hallmark of Ecstasy use is a profound feeling of "connectedness" with people: this is obviously a very attractive quality for a teenager who might be feeling detached from society or from a peer group.
Users of Ecstasy also report enhanced tactile sensations. More than one of my patients has told me: "I just love the feeling of being touched while I'm on E." Interestingly, while one might assume that this quality might lead to increased sexual activity, the sympathetic action of MDMA reportedly precludes any erectile response leading to such activity.
Many adolescents are under the mistaken impression that MDMA is safe. It is our responsibility to explain the risks. MDMA causes hyperthermia, with temperatures that often exceed 40.5°C (105°F). Accordingly, rave clubs typically provide air-conditioned spaces in which users are expected to "cool down" when not dancing. In addition, MDMA users will often consume large amounts of ice water to lower their body temperature as much as possible (remember Michael's use of bottled water?). Persons who take Ecstasy water-load while under the drug's influence, which can result in dilutional hyponatremia. It is not uncommon for Ecstasy users to present in status epilepticus because of the profound hyponatremia caused by the combination of water-loading and the salt loss from sweating.
Other risks involved with Ecstasy ingestion are arrhythmias and hepatotoxicity. In addition, the drug can cause profound hypoglycemia, which is why many users at a rave will be seen sucking on lollipops (which also helps with the bruxism).
Over the past 5 years, data have emerged suggesting that Ecstasy—even when used sparingly—can have long-term neurologic consequences. The acute increase in serotonergic activity is later replaced by a lack of serotonin in the synapses. Obviously, any patient who is sensitive to deceased serotonin levels (especially those with depression, anxiety, or any serotonin-based psychiatric condition) must be counseled against use of this drug: a post-use dysphoria can ensue that may last weeks to months before the serotonin in the brain is replenished. Even those who have used Ecstasy for short periods have demonstrated a "pruning" of serotonergic axons and terminals that subsequently affects the brain's ability to perform complex thought and higher-function processes.
Finally, be sure to inform adolescent patients of recent data suggesting that Ecstasy use can result in a frequency-dependent memory reduction. This effect appears to persist for years after use of the drug is discontinued.1-3