ecstasy & party drugs

Ecstasy & Party Drugs



Party Drugs: GP’s Role

• GPs will see increasing presentations related to problems associated with ‘Party Drugs’

• Types of drugs available change regularly

• Increasing diversity of drugs used

• A range of drugs, variously called ‘Designer’ or ‘Party Drugs’ includes PMA, MDA, GHB and Ecstasy


Case StudyAndy, a 28 year old engineer, was referred to you by the local hospital Emergency Department after he collapsed at a dance party. He was placed under observation then discharged to your care, as his GP.

You were not previously aware that Andy used recreational drugs.

What would you include in your assessment?

How would you assist Andy to avoid similar situations?


• MDMA is generally classed as a stimulant with mild hallucinogenic properties

• MDMA enhances extracellular concentrations of:

– serotonin

– dopamine

• All amphetamine-type substances share common effects and problems related to their use.

MDMA/Ecstasy:3,4-methylenedioxymethamphetamine


How Ecstasy is UsedForms

• tablets, capsules, powder, liquid

Routes of administration• oral (crushed / snorted), smoked, anal (‘shelved’) or

inserted in vagina (‘shafted’), some IV use

Dose • normally 75–150 mg in one good quality tablet

• usual dose is 1–2 tablets, although more may be taken if desired effect not reached.


Who Uses Party Drugs?• Young, usually mid-teens or early to mid-20s

• More common amongst young males

• Relatively well-educated, employed or studying

• Little contact with police, social authorities, or treatment agencies

• Unlikely to be from socially deprived backgrounds

• Unlikely to have incarceration history.

Party Drugs = ecstasy + others; e.g. ketamine, GHB, ‘pills’ which may or may not have stimulant properties.


Patterns of Party Drug Use

• around 25% use weekly to fortnightly

• around 60% report ‘bingeing’ within last 6 months

• 52% reported ecstasy as their favourite drug

• polydrug use common (average 6–7 drugs used in last 6 months)

• injection rare

• prevalence increased in recent years.IDRS (2002); NHS (2001)

In 2001, almost 1 million (6.1%) Australians >14 years had ever used ecstasy/designer drugs. Typically:


Party Drugs and Polydrug UsePolydrug use is common. Combinations include:

• other depressants (e.g. alcohol, cannabis, benzodiazepines)

• other stimulants (e.g. speed, tobacco, cocaine)

• hallucinogens (e.g. LSD)

• other drugs (e.g. amyl nitrite, ketamine, GHB).


Manipulation of molecular structures of amphetamines results in the production of other drugs such as the more potent PMA

(paramethoxymethamphetamine).

MDMA / Ecstasy:3,4-methylenedioxymethamphetamine


Ecstasy Stimulates Serotoninserotonin cells

Serotonin cells in a rat’s brain, stimulated by ecstasy to release serotonin

serotonin (red dots)from axon terminals

serotonin neurones(yellow)


The ‘Ecstasy Experience’

Coming down• Physical exhaustion, flat, depressed, tired, anxious

irritable, paranoid• Comedown more intense

if IDU / polydrug user

Coming up • Tightening of muscles, esp. jaw• dilated pupils, visual distortions• Smooth or suddennausea or vomiting

• Strong pulse, incr. temp• Confusion, panic.

0 4 8

Plateau• Feel good, happy, relaxed, open, loving

• Heightened senses• Energy, confident, talkative

• Decreased urine output• Increased thirst.

Hours After Ingestion


MDMA & Related Drugs:Effects of Short-term, Low-High Dose


Problems Associated with Short-term Use

Immediate (post-administration)• Hyperthermia, dehydration, overhydration/hyponatraemia• Safety issues• Overdose.

Short term problems• Finances, work or study • Relationships• Mood and mental health.


Long-term Use

• Increased negative or undesired effects

• Increased tolerance leading to increased dosage

• Potential neurotoxicity.


Ecstasy Overdose• Fluid retention / renal failure

• Agitation, confused mental state, disordered speech, psychosis, hallucinations, convulsions, severe headache

• Tachycardia (resting heart rate >120 bpm)

• Hypertension / hypotension

• Hyperthermia (temp >38.6o C )

• Nausea or vomiting

• Excessive fluid consumption

• Muscle rigidity

• Death.

In the case of overdose refer to the

Emergency Department


Ecstasy: Treatment of Overdose or Complications

Hyperthermia cool compresses, sponging, hypothermia blankets, iced baths. Medical intervention may include Dantroline (muscle relaxant)

Rhabdomyolysis assess and monitor urine output, ensure hydration. Indications of renal failure require urgent medical attention ? haemodialysis

Hypertension reduce stimuli, encourage relaxation. arrhythmias May require medication

Convulsions usual seizure management, life support, hospitalisation

Intensive Care may be required so do NOT delay referral.


Assessing PatientsInclude:

• lifestyle issues in relation to use of ecstasy and other party drugs

• polydrug use and implications

• use trigger questions about:

– patterns of use– potential harms (including physical safety and

emotional health and wellbeing)– contact with other drugs / drug users– work or study performance– quality of personal and social relationships.


GP Interventions: EcstasyInterventions include:• brief interventions• harm reduction• assessment, screening and monitoring for

depression • Emergency Department referral for overdose.

Treatment:• psychosocial support and counselling • unlikely that most people who use ecstasy will

require long-term interventions.


Harm Reduction AdviceGPs can advise patients to...Plan:

• eat first, don’t mix drugs, limit use• take breaks from dancing• maintain fluid and food intake• develop safety plans.

‘Come Down’ carefully: • avoid using other drugs • sleep it off• plan ‘using’ and ‘recovery’ time • understand the consequences associated

with using and coming down.

In general:• undertake physical and emotional self-care.


Harm Reduction:

Ecstasy is contraindicated if family history of:

• heart disorders, hypertension or cardiovascular disease

• mental health problems, or use of antidepressants such as Prozac, Aropax, Zoloft, Aurorix, or MAOIs

• neurological / nervous system impairment

• kidney disease

• obesity managed with medication

• previous severe or unpleasant reaction to ecstasy.

Contraindications for Ecstasy Use


Dependence on Ecstasy

• Low likelihood of physical dependence

• Tolerance tends to result in reduced effects, reduced enjoyment, and ‘loss of the ecstasy magic’ as lifetime use increases.


Ketamine and PCP• Ketamine may be called Special K, kitkat,

Vitamin K, K, Ket

• PCP may be called angel dust, peace pill, crystal, hog, horse tranquilliser)

• Produces a dissociative state

– detachment

– disorientation

– disordered thoughts

– loss of proprioception.


Ketamine and PCP Recreational Use

• Both sold as pills, tablets, capsules or powder, and snorted, swallowed, smoked or injected

• Some opioid-like effects (incl. respiratory depression)

• Onset of effect varies with route of administration (30 sec (IV) to 10–20 mins (oral))

• Duration of action: – ketamine 1–3 hours– PCP 4–6 hours.


Ketamine and PCP Medical Use

• Primarily used as a short acting anaesthetic in surgical procedures

• Especially useful for children under 10 years, or older people (over 60 years)

• Popularity:

– popularity grew in 1980s and 1990s – widely perceived as a ‘date-rape

drug’ and ‘club drug’.


Ketamine and PCP Effects

Short-term Adverse Long-term• Euphoria • Anxiety • Dependence• Hallucinations

• Pleasant stimulation

• Perceptual distortions

• Numbness of extremities.

• Agitation

• Paranoia

• Stupor

• Amnesia

• Depression

• Hostile / violentbehaviour

• Flashbacks

Major Problems Are Rare


Ketamine and PCP Overdose

• Ketamine:

– wider margin of safety

– respiratory depression possible, with complete recovery

• PCP:

– acute hypertensive crisis

– convulsions, coma, death.


Ketamine and PCP ToxicityAcute Toxicity – Low Dose

• Resembles alcohol intoxication

• Ataxia, slurred speech, nystagmus, euphoria & numbness in the extremities.

Chronic Toxicity• Chronic effects not well

researched - include personality changes, difficulty with memory, speech and thinking.

Acute Toxicity – High Dose• Distorted sensory perception and

disorganised thought

• Drowsiness and apathy

• Hostile or bizarre behaviour

• Anaesthesia

• Catatonic-like muscle rigidity and convulsions

HR & BP

• Sweating and fever

• Myoclonus

• Respiratory depression and coma

Pupillary & corneal reflexes.


GHB:

• ‘Fantasy’, ‘grievous bodily harm’ (GBH), liquid ecstasy

• Laboratory manufactured. Also produced in the brain through synthesis of GABA

• Developed as an anaesthetic, but withdrawn

• Sedative effects vary between individuals

• Affects some neurotransmitters.

Gammahydroxybutyrate or Sodium Oxybate


GHB Recreational Use

• Like alcohol, used as a recreational intoxicant

• Associated with dance music scene

• May assist with sleep

• Body builders may use GHB to increase production of growth hormone.


How GHB is UsedForm

• colourless, odourless liquid (from powder mixed with water). May be slightly salty or bitter to taste.

Dose • usual dose is around 1–3 g powder;

approx. 1 g : 1 ml water (i.e. 5 g per teaspoon). Concentration is widely variable.

Route• oral, less often IV.

Onset• 10–60 minutes.


GHB: Duration of Effect

Onset 10–20 minutesComing up 15–20 minutesPlateau 45–90 minutes Coming down 15–30 minutesAfter effects 2–4 hours


GHB Effects (1)

Small dose (1–3 g)• Decreased inhibitions• Increased libido• Euphoria similar to

ecstasy• Sedative effects• Memory loss (sedation)• Synergistic effect when

combined with alcohol (significantly increases risk of overdose).

Larger Dose (4–5 g)• Powerful sedative effects• Nausea and vomiting• Stiffening of muscles• Disorientation• Profound sedation• Convulsions• Coma• Respiratory collapse.


GHB: Overdose and Long-term Use

• Overdose risk if mixed with other CNS depressants:

– respiratory depression

– diaphoresis

– ‘eyes rolling’

– muscular spasms, convulsions

• Those hospitalised in Australia have made full recovery

• Potential for dependence, with symptoms similar to alcohol

• Other long-term consequences unknown.


• Synthetic amphetamine, stimulant and hallucinogenic properties, usually produced in clandestine laboratories

• Not MDMA, though sold as MDA, MDMA, speed. Potency >6 times MDMA

• No known indications for its medical use.

Form• White crystalline to yellow or amber, may be powder,

chunks, ‘gummy’ material, capsules, tablets, powders.

Route• Sniffed, swallowed, IV.

PMA:Paramethoxyamphetamine


PMA: Short-term EffectsCNS

• Behavioural (subjective)• Hallucinations, delirium, convulsions, coma• Restlessness, agitation, hyperactivity• Muscle contractions, rigidity• Hyperthermia, sweating.

Cardiovascular system• Tachycardia, unknown effects on BP.

Gastrointestinal system• Nausea and vomiting.


PMA: High Risk and Long-term Effects

• High doses can be fatal

• PMA-related deaths have been confirmed

• Effects of long-term use are unknown:

• ? if long-term use leads to tolerance or dependence

• specific patterns of use are unknown, as PMA is often sold as MDMA, MDA or other designer drugs.


LSD



LSD: Pharmacology

• Street dose typically around 0.1–0.5 mg

• Multiple receptor actions (partial agonist effects at 5-HT2 and D1 and D2 receptors)

• Onset of action between 30–60 minutes; ppc of 2–4 hours

• Acute psychotic symptoms can occur as a result of activation of serotonin receptors.


LSD EffectsLargely sympathomimetic:

• pupillary dilatation

• ↑ BP

• tachycardia

• hyper-reflexia

• tremor

• nausea

• piloerection

• muscular weakness

• ↑ temperature.

Non-sympathomimetic:

• dizziness

• weakness

• drowsiness

• paraesthesia

• emotional lability.


LSD: Chronic Effects

• Flashbacks (experienced by 15% of users)

• No evidence of long-term toxicity

• Some evidence for reduced capacity for abstract thinking with repeated use

• Tolerance to subjective and behavioural effects develops rapidly but not to autonomic effects

• Risk of dependence is low.


Psilocybin• Psilocybin is found in psilocybe (and some other)

mushrooms. Concentration varies with mushroom age and conditions of growth (i.e. light)

• 2–4 mushrooms produce relaxation and wellbeing; 20–30 produce a full LSD-like response

• Effects: 6–8 hours followed by drowsiness

• Acute toxic effects include agitation, panic, psychosis and ataxia

• Chronic toxicity is not well documented.


Anticholinergics• Datura stramonium contains hyoscine

• Effects: delirium, changes in cognition, awareness and memory, delusions

• Low doses

– dry mouth, blurred vision, mydriasis, urinary retention and tachycardia

• Higher doses

– hallucinogenic effects

• Toxicity resembles other hallucinogens.

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