Ecstasy & Party Drugs

1. Ecstasy & Party Drugs

2. 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

3. Case Study Andy, 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?

4. MDMA/Ecstasy: 3,4-methylenedioxymethamphetamine • 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.

5. How Ecstasy is Used Forms • 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.

6. 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.

7. Patterns of Party Drug Use In 2001, almost 1 million (6.1%) Australians >14 years had ever used ecstasy/designer drugs. Typically: • 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)

8. Party Drugs and Polydrug Use Polydrug 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).

9. MDMA / Ecstasy: 3,4-methylenedioxymethamphetamine Manipulation of molecular structures of amphetamines results in the production of other drugs such as the more potent PMA (paramethoxymethamphetamine).

10. Ecstasy Stimulates Serotonin serotonin cells serotonin neurones(yellow) serotonin (red dots)from axon terminals Serotonin cells in a rat’s brain, stimulated by ecstasy to release serotonin

11. The ‘Ecstasy Experience’ • Plateau • Feel good, happy, relaxed, open, loving • Heightened senses • Energy, confident, talkative • Decreased urine output • Increased thirst. • 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 sudden • nausea or vomiting • Strong pulse, incr. temp • Confusion, panic. 4 0 8 Hours After Ingestion

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

13. 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.

14. Long-term Use • Increased negative or undesired effects • Increased tolerance leading to increased dosage • Potential neurotoxicity.

15. 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

16. Ecstasy:Treatment of Overdose or Complications Hyperthermiacool compresses, sponging, hypothermia blankets, iced baths. Medical intervention may include Dantroline (muscle relaxant) Rhabdomyolysisassess and monitor urine output, ensure hydration. Indications of renal failure require urgent medical attention ? haemodialysis Hypertensionreduce stimuli, encourage relaxation.arrhythmias Mayrequire medication Convulsionsusual seizure management, life support, hospitalisation Intensive Care may be required so do NOT delay referral.

17. Assessing Patients Include: • 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.

18. GP Interventions: Ecstasy Interventions 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.

19. Harm Reduction Advice GPs 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 associatedwith using and coming down. In general: • undertake physical and emotional self-care.

20. Harm Reduction: Contraindications for Ecstasy Use 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.

21. 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.

22. 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.

23. 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.

24. 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’.

25. Ketamine and PCP Effects Major Problems Are Rare

26. Ketamine and PCP Overdose • Ketamine: • wider margin of safety • respiratory depression possible, with complete recovery • PCP: • acute hypertensive crisis • convulsions, coma, death.

27. Acute 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. Ketamine and PCP Toxicity

28. GHB: Gammahydroxybutyrate or Sodium Oxybate • ‘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.

29. 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.

30. How GHB is Used Form • 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.

31. GHB: Duration of Effect Onset 10–20 minutes Coming up 15–20 minutes Plateau 45–90 minutes Coming down 15–30 minutes After effects 2–4 hours

32. 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 Effects (1)

33. 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.

34. PMA: Paramethoxyamphetamine • 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.

35. PMA: Short-term Effects CNS • 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.

36. 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.

37. LSD Ecstasy & Party Drugs

38. 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.

39. LSD Effects Non-sympathomimetic: • dizziness • weakness • drowsiness • paraesthesia • emotional lability. Largelysympathomimetic: • pupillary dilatation • ↑ BP • tachycardia • hyper-reflexia • tremor • nausea • piloerection • muscular weakness • ↑ temperature.

40. 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.

41. 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.

42. 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.