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Club Drugs

The drugs methylenedioxymethamphetamine (Ecstasy/MDMA), gamma hydroxybutyrate (GHB), flunitrazepam (Rohypnol®), and ketamine are used by college students and by a segment of the youth population that attends all-night dance parties known as “raves.” For this reason, this group of drugs has become known as “club drugs.”Individuals susceptible to addiction can become compulsive users of these drugs and develop a psychological dependence.BackgroundPeople take club drugs to enhance their party or social experience, lower inhibitions, and boost energy for extended periods.¹ This may include stimulants, depressants, and hallucinogens if used for this purpose.Club drugs often appeal to younger drug users and present the possibility of significant toxicity that can be life threatening or result in permanent morbidity.²Club drugs are used to increase feelings of closeness with others and to heighten the experience through sensory enhancement, visual distortion, and illusion.³Epidemiology is the study of the determinants, occurrence, and distribution of health and disease in a defined population. Most epidemiologic data on club drug use focuses on MDMA.Perpetrators use these drugs in drug-induced sexual assaults because of their effects, and these drugs may be referred to as “date rape drugs.”People often describe club drug use as a youth movement. While college may be the time of first MDMA use, use in high school students has become more common. The Youth Risk Behavior Survey 2019 reported that 3.6% of high school students nationwide had used MDMA at least once during their lifetimes.^4,5In 2020, a total of 1.8% of high school seniors had consumed MDMA during the previous year, and approximately 0.3% admitted to being current users.⁶A survey of 14,000 college students at 119 American colleges found a 69% increase in MDMA use between 1997 and 1999 (from 2.8% to 4.7%), with little change in cannabis use during the same period.⁷During the 1990s and 2000s, MDMA became one of the most common psychoactive drugs used in bars and clubs in many areas of the country. In one survey, 89% of young adults attending clubs reported lifetime MDMA use, compared with 18% of a sample of youthful offenders.⁸In a drug recovery program in Seattle, individuals 14 to 24 years of age, 44% had used MDMA; 43% of those older than 25 years of age also reported past MDMA use.¹Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports that MDMA related emergency department visits by patients younger than 21 years of age increased from 4,460 in 2005 to 10,176 in 2011.⁹ Each year, an average of 33% of visits involving MDMA also involve alcohol.Ecstasy/MDMA – MethylenedioxymethamphetamineMDMA possesses both stimulant and hallucinogenic properties.¹⁰ It produces an energizing effect, distortions in time and perception, and enhanced enjoyment of tactile experiences.MDMA is a synthetically produced drug. Western Europe is the primary source for MDMA seized in the United States.In the past 10 to 15 years, the trafficking pattern of MDMA has shifted. Most MDMA, in the United States, is being manufactured in Asia and shipped through Canada and the Netherlands.^11,12MDMA is a Schedule I drug under the Controlled Substance Act, meaning it has a high potential for abuse, no currently accepted medical use in treatment in the United States and a lack of accepted safety for use under medical supervision.¹³What are the common street names?Adam, Beans, Clarity, Disco Biscuit, E, Ecstasy, Eve, Go Hug Drug, Lover’s Speed, MDMA, Peace, STP, X and XTC.¹³What are the effects on the mind?MDMA affects brain cells that use the chemical serotonin to communicate with each other. Serotonin helps to regulate mood, aggression, libido (sex drive), sleep, and sensitivity to pain.¹³It causes changes in perception. This includes euphoria, increased sensitivity to touch, energy, sensual and sexual arousal, need to be touched, and need for stimulation.¹³What are the overdose effects?In high doses, MDMA can interfere with the body’s ability to regulate temperature. This may lead to sharp increases in body temperature (hyperthermia), resulting in liver, kidney or cardiovascular system failure, swelling of the brain and even death.¹³TreatmentIt is uncommon for individuals to seek treatment for MDMA abuse or dependence. There are no clear guidelines for treatment, and there are no specific treatment recommendations for either helping curb MDMA abuse or countering its consequences. Patient education is essential in communicating the short- and long-term risks of MDMA use.¹⁴GHB – Gamma HydroxybutyrateMany internet sites offer instructions for the home production of GHB or advertise the sale of kits that contain the ingredients necessary to produce the drug. The chemical precursors of GHB are gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD). GBL is found in household solvents. Following ingestion, GBL is rapidly converted to GHB by endogenous lactonase, and 1,4-BD is metabolized in the body by alcohol dehydrogenase to gamma-hydroxy butyraldehyde, which is in turn metabolized to GHB by aldehyde dehydrogenase.Both precursors became popular sources of the drug, with 1,4-BD available in health stores, and both available on the internet.^15,16 However, GBL and BD are now considered controlled substance analogs.¹⁶GHB is a naturally occurring, short-chain fatty acid metabolite of gamma-aminobutyric acid (GABA). It acts as a CNS depressant and induces rapid eye movement (REM) sleep within 15 minutes.GHB was originally developed as an anesthesia agent during the 1950s. Its effectiveness was limited by the tendency to induce substantial nausea, vomiting, and seizures, and its use was discontinued because of suboptimal analgesic properties and the development of new, more effective anesthetic agents.The average dose ranges from 1 to 5 grams (depending on the purity of the compound, this can be 1-2 teaspoons mixed in a beverage). However, the concentration of these “home brews” have varied so much that users are usually unaware of the actual dose they are drinking.¹⁶At bars or “rave” parties, GHB is typically sold in liquid form by the capful or “swig.”¹⁶What are the common street names?Easy Lay, G, Georgia Home Boy, GHB, Goop, Grievous Bodily Harm, Liquid Ecstasy, Liquid X and Scoop.¹⁶What are the effects on the mind?GHB occurs naturally in the central nervous system in very small amounts. Use of GHB produces central nervous system depressant effects including¹⁶:

• Euphoria.
• Drowsiness.
• Decreased anxiety.
• Confusion.
• Memory impairment.

What are the effects on the body?GHB takes effect in 15 to 30 minutes, and the effects last 3 to 6 hours. Low doses of GHB produce nausea. At high doses, GHB overdose can result in¹⁶:

• Unconsciousness.
• Seizures.
• Slowed heart rate.
• Greatly slowed breathing.
• Lower body temperature.
• Vomiting.
• Nausea.
• Coma.
• Death.

Regular use of GHB can lead to addiction and withdrawal that includes¹⁶:

• Insomnia.
• Anxiety.
• Tremors.
• Increased heart rate and blood pressure.
• Occasional psychotic thoughts.

TreatmentThere is no antidote available for GHB intoxication and treatment is limited to supportive care.Rohypnol^® – FlunitrazepamFlunitrazepam is a member of the benzodiazepine class of anxiolytics and hypnotics.¹⁷ It has been a widely prescribed sleep aid throughout the world and is approved for therapeutic use in Latin America, Europe, Asia, and Australia for treating insomnia and as a presurgical anesthetic.Although not manufactured or approved for medical use in the United States, flunitrazepam is smuggled into the country from Mexico.^17,18What are the common street names?Circles, Forget Pill, Forget-Me-Pill, La Rocha, Lunch Money Drug, Mexican Valium, Pingus, R2, Reynolds, Roach, Roach 2, Roaches, Roachies, Roapies, Robutal, Rochas Dos, Rohypnol, Roofies, Rophies, Ropies, Roples, Row-Shay, Ruffies and Wolfies.^17,19How is it abused?

• Flunitrazepam can be swallowed whole, crushed and snorted, or dissolved in liquid. The effects are experienced within 30 minutes, peak within 1 to 2 hours, and continue for an average of 8 to 10 hours. The drug has a half-life of 19 to 23 hours.¹⁸
• Adolescents may abuse Rohypnol^® to produce a euphoric effect often described as a “high”. While “high” they experience reduced inhibitions and impaired judgment.¹⁷
• Rohypnol^® is also used in combination with alcohol to produce an exaggerated intoxication.¹⁷
• In addition, abuse of Rohypnol^® may be associated with multiple-substance abuse. For example, cocaine users may use benzodiazepines such as Rohypnol^® to relieve the side effects (e.g., irritability and agitation) associated with cocaine binges.¹⁷
• Perpetrators also misuse Rohypnol^® to physically and psychologically incapacitate victims targeted for sexual assault. Perpetrators place Rohypnol^® in the alcoholic drink of an unsuspecting victim to incapacitate them and prevent resistance to sexual assault. The drug leaves the victim unaware of what has happened to them.

What are the effects on the mind?Rohypnol^®, like other benzodiazepines, slows down the functioning of the central nervous system producing¹⁷:

• Drowsiness (sedation).
• Sleep (pharmacological hypnosis).
• Decreased anxiety.
• Amnesia (no memory of the events while under the influence of it).

Rohypnol^® can also cause¹⁷:

• Increased or decreased reaction time.
• Impaired mental functioning and judgment.
• Confusion.
• Aggression.
• Excitability.

What are the effects on the body?Rohypnol^® causes muscle relaxation. Adverse physical effects include¹⁷:

• Slurred speech.
• Loss of motor coordination.
• Weakness.
• Headache.
• Respiratory depression.

Prolonged use of flunitrazepam can result in physical dependence. Withdrawal symptoms can develop when the user stops or dramatically cuts back.¹⁷TreatmentFlunitrazepam, as a benzodiazepine, is the only club drug with a known antidote. Flumazenil reverses the effects but must be used with caution in patients with polydrug ingestion because seizures and cardiac arrhythmias can be precipitated.⁸KetamineKetamine is a phencyclidine (PCP) derivative with a combination of sedative, anesthetic, amnesiac, and analgesic properties. Ketamine has one-tenth the potency of PCP and a considerably briefer duration of action. This drug is used for medicinal and veterinary purposes when CNS dissociation is desired. Illicitly, it appears as a white powder that is snorted, taken orally, injected intravenously or intramuscularly, or smoked. Users of ketamine are attracted to the hallucinogenic effects, described as an “out-of-body experience” similar to that produced by LSD and PCP.²⁰Ketamine is an approved medical product as an injectable, short-acting anesthetic for use in humans and animals and as esketamine (Spravatol^®; the active form of the drug) as a nasal spray for treatment resistant depression.²¹Ketamine is difficult to manufacture. Veterinary settings account for 90% of legal ketamine use. Illicit ketamine is obtained by diverting the pharmaceutical product, typically of veterinary origin.²What are the common street names?Cat Tranquilizer, Cat Valium, Jet K, Kit Kat, Purple, Special K, Special La Coke, Super Acid, Super K and Vitamin K.²¹Ketamine comes in a clear liquid and a white or off-white powder. Powdered ketamine is cut into lines known as bumps and snorted or it is smoked, typically in marijuana or tobacco cigarettes. Ketamine may be found by itself or in combination with MDMA, amphetamines, methamphetamine, or cocaine.²¹What are the effects on the mind?Low doses of ketamine are associated with feelings of relaxation, while higher doses can produce dreamlike states, hallucinations, visual distortions, and unpleasant sensations of near-death experience.²The onset of effects is rapid and often occurs within a few minutes of taking the drug, though taking it orally results in a slightly slower onset of effects.Some common effects of ketamine use are delirium, amnesia, and depression. Adverse effects include nausea, immobility, abnormally low body temperature, anxiety, dissociation, depression, recurrent flashbacks, impaired attention, learning disability, and symptoms of schizophrenia.²Cognitive dysfunction related to attention, learning, and memory can result from chronic abuse.²Hallucinogen Persisting Perception Disorder (HPPD) has been reported several weeks after ketamine use, and may include experiencing prolonged visual disturbances.^21,23What are the effects on the body?Increased heart rate and blood pressure that gradually decreases over the next 10 to 20 minutes. Ketamine can make users unresponsive to stimuli. When in this state, users experience²¹:

• Involuntary rapid eye movement.
• Dilated pupils.
• Salivation.
• Tear secretions.
• Stiffening of the muscles.
• Possible nausea.

TreatmentBecause no antidote exists for ketamine intoxication, supportive care requires special attention to respiratory and cardiac function. Intramuscular diazepam (Valium) or midazolam (Versed) should be considered for patients requiring sedation.^1,22To date, no treatment modalities specifically tailored to ketamine abuse or dependence have been published in peer-reviewed literature.²⁴

Conclusion

• Although club drugs are often used in party or social settings to enhance experiences of the environment, extended use can result in many untoward effects.
• The acute and long-term effects of club drug use may be similar to other medical or mental health conditions.
• In addition to their use recreationally, some club drugs have been used to facilitate sexual assault.

References

1. Smith KM, Larive LL, Romanelli F. Club drugs: methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate. Am J Health-Syst Pharm. 2002;59(11):1067-1076.
2. Britt GC, McCance-Katz EF. A brief overview of the clinical pharmacology of “club drugs.” Subst Use Misuse. 2005; 40 (9-10):1189- 1201.
3. Rimsza ME, Moses KS. Substance abuse on the college campus. Pediatr Clin North Am. 2005; 52(1):307-319.
4. Jones CM, Clayton HB, Deputy NP, et al. Youth Risk Behavior Surveillance—United States, 2019. MMWR. 2020; 69 (Suppl-1):40-46.
5. U.S. Department of Health and Human Services. Trends in the Prevalence of Marijuana, Cocaine, and Other Illegal Drug Use National YRBS: 1991–2019. Available at https://www.cdc.gov/healthyyouth/data/yrbs/factsheets/2019_us_drug_trend_yrbs.htm.
6. Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2020). Monitoring the Future national survey results on drug use 1975-2019: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan. Available at mtf-overview2019.pdf (monitoringthefuture.org).
7. El-Mallakh RS, Abraham HD. MDMA (Ecstasy). Ann Clin Psychiatry. 2007;19(1):45-52.
8. Greene JP, Ahrendt D, Stafford EM. Adolescent abuse of other drugs. Adolesc Med Clin. 2006;17(2):283-318.
9. Substance Abuse and Mental Health Services Administration. The DAWN Report: Ecstasy-Related Emergency Department Visits by Young People Increased Between 2005 and 2011; Alcohol Involvement Remains a Concern. Available at https://www.samhsa.gov/data/sites/default/files/spot127-youth-ecstasy-2013/spot127-youth-ecstasy-2013.pdf.
10. Morton J. Ecstasy: pharmacology and neurotoxicity. Curr Opin Pharmacol. 2005;5(1):79-86.
11. American Addiction Centers. Ecstasy Statistics and History. Available at https://drugabuse.com/drugs/ecstasy/history-statistics.
12. U.S. Drug Enforcement Administration. 2020 National Drug Threat Assessment (NDTA) Summary. Available at https://www.dea.gov/sites/default/files/2021-02/DIR-008-21%202020%20National%20Drug%20Threat%20Assessment_WEB.pdf.
13. U.S. Drug Enforcement Administration. DEA Drug Fact Sheet: Ecstasy/MDMA. Available at Drug Fact Sheet: Ecstasy/MDMA (dea.gov).
14. Hahn I-H. MDMA Toxicity. Available at https://emedicine.medscape.com/article/821572-overview.
15. Andresen H, Aydin BE, Mueller A, Iwersen-Bergmann S. An overview of gamma-hydroxybutyric acid: pharmacodynamics, pharmacokinetics, toxic effects, addiction, analytical methods, and interpretation of results. Drug Test Anal. 2011;3(9):560-568.
16. U.S. Drug Enforcement Administration. Drug Fact Sheet: GHB. Available at Drug Fact Sheet: GHB (dea.gov).
17. U.S. Drug Enforcement Administration. DEA Drug Fact Sheet: Rohypnol. Available at Drug Fact Sheet: Rohypnol (dea.gov).
18. Klein M, Kramer F. Rave drugs: pharmacological considerations. AANA J. 2004;72(1):61-67.
19. U.S. Drug Enforcement Administration. Drugs of Abuse: A DEA Resource Guide, 2017 Edition. Available at Drugs of Abuse (2017 Edition) (dea.gov).
20. Li JH, Vicknasingam B, Cheung YW, et al. To use or not to use: an update on licit and illicit ketamine use. Subst Abuse Rehabil. 2011;2:11-20.
21. U.S. Drug Enforcement Administration. DEA Drug Fact Sheet: Ketamine. Available at Drug Fact Sheet: Ketamine (dea.gov).
22. D’Orazio J. Hallucinogen Toxicity Treatment and Management. Treatment: Prehospital Care. Available at https://emedicine.medscape.com/article/814848-treatment.
23. HPPD: Symptoms, causes, and treatment (medicalnewstoday.com).
24. Ivan Ezquerra-Romano I, Lawn W, Krupitsky E, Morgan CJA. Ketamine for the treatment of addiction: Evidence and potential mechanisms. Neuropharmacology. 2018;142:72-82. doi:10.1016/j.neuropharm.2018.01.017.

Cynthia Blair RN MA–March 2024