“Rave” Drugs OTCs Drugs in Sport

1. “Rave” Drugs OTCsDrugs in Sport Pearl Isaac & Anne Kalvik

2. Learning Objectives • To become aware of some substances used on the rave/club scene and their risks • To recognize OTC products that are abused and their effects • To develop an understanding of substances abused in sports and their consequences

3. “Rave” Scene • is it over? • PLUR • clubs, parties • younger users • older users & different patterns of use • raves & alcohol, cannabis use (why not?)

4. alcohol 66.2% cannabis 29.6% tobacco 19.2% hallucinogens 10% stimulants 5.8% solvents 6.1% LSD 2.9% methamphetamine 3.3% methylphenidate 2.9% MDMA 4.1% cocaine 4.8% ketamine 2.2% heroin 1.4% GHB 0.7% Ontario School Drug Use Survey 2003

5. Drugs Used on the “Rave” Scene(or by adolescents) • LSD • Ecstasy (MDMA) • Herbal Ecstasy • Ketamine (“Special K”) • Methamphetamine (“Crystal Meth”) • Psilocybin (Magic Mushrooms) • GHB • Rohypnol?

6. MDMA (Ecstasy) • Ecstasy, e, XTC, X , Adam, MDM, hug drug • branding (logos) • price • doses • purity & strength • amphetamine derivative with hallucinogenic properties, but...

7. MDMA: Effects • euphoria, energy • increased self-esteem, confidence • increased sociability, benevolence • visual distortions (minimal) • some anxiety, panic, confusion • paranoia • “hangover” • seizures, death

8. MDMA: Acute Effects • grinding of teeth (jaw pain) • sweating, hyperthermia (rhabdomyolysis possible) • high BP, increased heart rate • decreased appetite • insomnia • headache, stiffness of back and legs • arrhythmias, stroke, MI

9. MDMA: Long-term Effects • weight loss • psychiatric issues: depression, memory loss • flashbacks • hepatotoxicity • neurotoxicity • MDMA plus Viagra =

10. MDMA and Harm Reduction • venues • volunteers, police • fluids • loose clothing • DI questions • other? SSRI’s?? • useful?

11. Ketamine “Special K” • anesthetic related to PCP • diverted from hospitals and vetrinarians • antagonist at NMDA receptor • “dissociation” • impaired thought processes & memory • confusion, dizziness, slurred speech • hallucinations, flashbacks • aspiration, respiratory depression

12. “Date-Rape” Drugs • GHB • Rohypnol • Ketamine • Benzodiazepines • Alcohol

13. GHB • Looks like water • Liquid X, Liquid Ecstasy, GBH, Easy Lay • Narrow therapeutic window • CNS depressant • date rape context • euphoria • dizziness, drowsiness, sedation

14. GHB: Overdose • nausea & vomiting • loss of consciousness • amnesia • coma • seizures • respiratory arrest

15. GHB • dependence • withdrawal

16. GHB Precursors (GBL, Blue Nitro)

17. Rohypnol (flunitrazepam) • “roofies” • availability • how abused • change in formulation • police seizures? • other benzodiazepines • alcohol

18. Jessica • 16 years old • goes to raves when she can • at raves, she uses “e”, “k” and “crystal meth” • reports feeling depressed over past 6 months • denies suicidal ideation or intent

19. Jessica issues?

20. OTCs • why abused? • patterns of abuse (chronic vs. recreational)

21. OTCs that are Abused • codeine preparations (e.g. Tylenol #1) • dimenhydrinate (e.g. Gravol) • sleep aids with diphenhydramine (e.g. Sleep-Eze D, Nytol) • dextromethorphan • caffeine

22. OTCs that are Abused • cold preparations • with antihistamines • with stimulants/decongestants: ephedrine, pseudoephedrine (e.g. Sudafed) • with alcohol (Nyquil “all of the above” plus dextromethorphan)

23. OTCs that are Abused • alcohol-containing preparations (including mouthwashes, aftershaves) • herbals • solvents • laxatives • ipecac

24. Dimenhydrinate / Diphenhydramine • antinauseants, sleep aids • teenagers for high • hallucinations • toxicity –seizures, psychosis, arrhythmias • chronic use of high doses • psychiatric patients • tolerance, dependence, withdrawal

25. Dextromethorphan • In 50% of cough and cold products (e.g. Robitussin DM, Nyquil, Contac Cold&Fever, Benylin DM etc.) • DXM, Robo, DEX • high doses for LSD-like high • toxicity: hypertension, seizures, hallucinations, coma • chronic use - psychiatric issues

26. OTC Stimulants • CAFFEINE • “Wake Ups”, an ingredient in many OTC’s • sold as energizer, to stay awake • herbal (Guarna, Herbal Ecstacy) • high doses associated with anxiety, mood, sleep disorders • dependence & withdrawal

27. OTC Stimulants • Street Stimulants • Caffeine, Ephedrine, Phenylpropanolamine • Pseudoephedrine (e.g. Sudafed)/Ephedrine • weight loss, sports, energy • precursor for methamphetamine • new legislation • herbals (e.g. ephedra herb, Ma Huang) • toxicity: stroke, arrhythmias, MI

28. OTC Abuse What can you do in the pharmacy?

29. Drugs Used in Sports Anabolic steroids (“roids”, “juice”)

30. Stimulants amphetamine, caffeine, pseudoephedrine clenbuterol modafinal diuretics laxatives beta-blockers pain relievers urine tampering probenecid hormones HCG, HGH, EPO thyroxine insulin, OCs mifespristone GHB antidepressants Other Drugs Used in Sports

31. local anesthetics, corticosteroids nutritional supplements (e.g. creatine) acetylcholine Deprenyl cannabis alcohol tamoxifen clomiphene blood-doping Other Drugs/Techniques Used by Athletes

32. Drugs Used in Sports • ergogenic • therapeutic • recreational

33. Anabolic Steroids • androgenic (masculinizing) • anabolic (tissue building) • human • veterinary

34. Medical Uses for Anabolic Steroids • testosterone deficiency in males (including delayed puberty • chronic tissue wasting conditions • anemia • osteoporosis • others

35. Reasons Why Athletes Use Anabolic Steroids • more lean mass & less body fat • increased endurance & strength • decreased recovery time • increased aggression & ability to compete • faster healing time from injuries • winning “edge” • better appearance

36. Reasons for Others to Abuse Anabolic Steroids • enhance physical appearance • improve physical condition • personal enjoyment (“high”) • increased self-esteem • personality disorders • coach/parent/scholarship pressure • employment (e.g. law enforcement) • withdrawal symptoms?

37. Patterns of Use • doses often 100x higher than for medical use • “cycling” • “pyramiding” • “stacking”

38. Some Injectable Steroids • nandrolone (Deca-Durabolin) • stanozolol (Winstrol V) • testosterone (Depo-Testosterone, Delatestryl, etc.)

39. Tetrahydrogestrinone(THG)

40. Some Oral Steroids • danazol (Cyclomen) • methyltestosterone (Metandren) • oxandrolone (Anavar) • stanozolol (Winstrol) • testosterone undecanoate (Andriol)

41. Adverse Effects of Anabolic Steroids • endocrine • testicular atrophy, impotence, acne, gynecomastia, masculinization etc. • liver • jaundice, hepatitis, cancer etc. • musculoskeletal • premature closure of long bones (adolescents) • tendon ruptures

42. Adverse Effects of Anabolic Steroids • cardiovascular • MI, enlarged heart, clots, increased LDL, decreased HDL, fluid retention • GI • nausea, vomiting, irritation • behavioural • “roid rage”, mood swings, anxiety, paranoia, insomnia, psychosis, changes in libido, etc.

43. Indirect Adverse Effects of Steroids • infections (hepatitis, HIV) • from needle sharing and improper technique • abscesses & clots • from improper injection technique, repeated injections at same site, contaminants • consequences of “roid rage”

44. Tolerance, Dependence & Withdrawal • no evidence of tolerance • physical dependence and withdrawal (may simulate opioid withdrawal) have been reported • psychological dependence ? euphoria ? reward mechanism in brain ? natural opioids • not included in DSM-IV

45. Treatment • psychosocial counselling • stop smoking • nutritional counselling • ? pharmacological treatment • ? prevention strategies • ? harm reduction