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of self, for example thinking they are stronger Substances than they are or even invulnerable. This can lead to some individuals becoming aggressive and Module 1981 causing physical harm to either themselves or the NO is more commonly known as the core people around them.3 component of the anaesthetic and analgesic Substance misuse: Two widely known for their Entonox, or laughing gas (the latter also being one properties and commonly used in the UK are of the street names; others include Hippy Crack, dissociative drugs and nitrous oxide (NO). , Chargers and NOS). When used recreationally, and methoxetamine are small NO containing canisters are “cracked” using From this CPD module you will learn: substances also abused for their dissociative a device known as a cracker. This allows pure NO properties. The 2018 NHS Digital survey into gas to be transferred to a balloon, the contents of • What a dissociative is and how they are used in the UK the , drinking and drug use habits of which can then be inhaled. Inhaling directly from • The way in which dissociative drugs exert their effect young people in England revealed that 4.1% of the canister itself is inherently dangerous due • Detailed information about two commonly misused , participants said they had used NO in the last to the high pressure exerted on the gas. Direct year, making it as commonly used as volatile inhalation can cause the throat muscles to spasm nitrous oxide and ketamine substances such as aerosols and glues. and instigate respiratory arrest in some users.6 • Information on lesser known dissociatives including phencyclidine, A 2019 UK government report stated that The gas is rapidly absorbed into the dextromethorphan and methoxetamine ketamine use in England and Wales was the bloodstream and travels to the brain in seconds. highest it had ever been at 0.8%, with people aged A rush of and dizziness is common, and 16 to 24 years almost four times as likely to use it, users often start giggling. Sounds can become ASHA FOWELLS, PHARMACIST Substances with these effects may be used when with 2.9% in England and Wales reporting use in distorted, coordination and awareness are usually people just want to ‘step outside themselves’, or the last year.4,5 affected to the point that the person will fall This CPD module on misused substances forget real life for a short while, and this is where focuses on drugs that are used for their recreational drugs that exert a dissociative effect dissociative effects. See C+D’s other CPD may often become abused.1,2 modules for information on substance misuse The dissociative effects stem from disruption of of at tinyurl.com/depressants1, the action of glutamate on N-methyl-D-aspartate image- and performance-enhancing drugs at (NMDA) receptors in the brain, which influence tinyurl.com/imageperfdrugs and at cognition (including learning and memory), tinyurl.com/stimulants1. emotion and pain perception. There may be an accompanying rise in , resulting Defining dissociatives in a sense of euphoria commonly experienced Dissociation can be defined as the sense of feeling with dissociative drugs, most frequently at the disconnected from yourself and the world around beginning of the experience.3 you. It can be a natural reaction to extreme stress The effects of dissociative drugs can be or trauma or a coping mechanism for individuals in unpredictable, but can include feelings of situations where they have no control. Dissociation detachment, numbness, disorientation, confusion can also occur as a symptom of certain mental and loss of co-ordination. Sensory perception health conditions, for example bipolar disorder, may be altered, leading to dizziness, nausea schizophrenia, anxiety, depression and post- and vomiting. Moreover, users may experience traumatic stress disorder. Furthermore, a rise in their heart and respiratory rate and dissociation is a well documented adverse effect of blood pressure, as well as body temperature. use and consumption.1 Psychological distress is not uncommon, There are some substances that can specifically presenting as feelings of panic, fear, anxiety and exhibit greater degrees of dissociation in users. paranoia. Users may feel an exaggerated sense NO canisters are “cracked” and the contents transferred to a balloon before being inhaled by the user

chemistanddruggist.co.uk/update-plus July 2021 | Module 1981 | Substance misuse: dissociative drugs | 1 of 3 over if not already sitting or lying down. Because hospitals. Ketamine has been on the World Health NO displaces air in the lungs, oxygen saturation Organisation’s Essential List of Medicines since is reduced, which can cause tachycardia and 1985 due to the fact it does not depress breathing paraesthesia (abnormal skin sensation). The or lower blood pressure during surgery, reducing effects usually pass quickly, with the user feeling the need for extensive patient monitoring. This back to normal within a few minutes. Having such makes it particularly useful in places without a short-term effects can be detrimental, however, reliable supply of oxygen or electricity, and in as it may encourage frequent redosing or other conflict and disaster situations. Ketamine also dangerous behaviours in an attempt to prolong has veterinary uses, which gives rise to some of the effects, for example putting a plastic bag over its colloquial names such as Donkey Dust and the head while inhaling.7 Horse Tranquilliser.12,13 Common side effects include headache and The most common administration route for nausea, as well as physical injury from loss of recreational ketamine is snorting, though it may coordination. Brain hypoxia is a very real risk, be injected into a muscle, swallowed in tablet particularly if using NO in an enclosed space form or wrapped in a cigarette paper (this is or in large quantities, which can lead to loss known as bombing). The onset of action varies of consciousness, cardiac abnormalities or accordingly, from around 15 minutes when suffocation. Regular or heavy use can deplete snorted to up an hour when ingested orally. The vitamin B12 levels, which in turn can lead to effects users seek are generally a dream-like, anaemia, as well as significant and sometimes detached sense of being with altered perception irreversible nerve damage.6,8,9 of time and space. However, it can cause nausea, Recreationally ketamine is usually snorted, but it can also be used medicinally as an anaesthic or analgesic NO is covered by the 2016 Psychoactive vomiting, confusion, injury through loss of Substances Act, rendering it illegal to produce or pain perception, agitation and panic attacks. the ketamine will not result in falling blood anaesthetic. It comes in many forms – oil, liquid, sell for its psychoactive effect, but not to possess. Excessive ketamine intake can lead to someone pressure and heart rate normally associated with powder, crystals, pills – with the colour ranging It can however be sold as an approved food experiencing a “k-hole” where the mind and depressants. The cardiovascular system may be from white to yellow and brown depending on additive for whipped cream propellant, giving it body feel completely separated for a period of unable to cope leading to potentially fatal adverse the presentation and purity. The substance may the street name “Whippits”. A paper prepared for time – this can be very frightening, especially effects. Combining ketamine with other drugs be sniffed, swallowed, smoked or injected. It a 2020 House of Commons debate cites concerns if someone is in an unfamiliar place or with can be fatal, particularly depressants, which can has a similar to ketamine, about the health impact of recreational NO, but unknown people. There can also be a significant increase the risk of collapse. The user is also at but with greater affinity and a longer duration also anti-social behaviour associated with using comedown after using the drug, during which risk of choking due to loss of consciousness and of action at NMDA receptors, meaning it is the drug, and littering of empty canisters in the individual can feel very low in mood and increased likelihood of vomiting.13,14,15 more likely to cause adverse effects including public places (some local authorities have issued anxious for several days.13 Although not physically addictive, psychological paranoia, aggression and psychosis, as well as Public Space Protection Orders that ban the Regular ketamine use can cause damage dependence can occur. Legally, ketamine is a Class a rise in body temperature which can lead to consumption of NO). The Royal College of Nursing to long-term memory and concentration, B drug, meaning the penalties for possession are multi-organ failure and issues of tolerance and has also highlighted the dangers, calling for better flashbacks, depression, exacerbation of pre- up to five years in prison and/or an unlimited fine, . It is a Class A drug, carrying with it public information on the risks and heightened existing mental health problems, psychosis, whereas supply carries with it a maximum 14-year a seven year prison sentence and/or unlimited awareness among healthcare professionals on abdominal cramps (sometimes called “k cramps”) prison sentence and/or an unlimited fine. As well fine for possession, increasing to a maximum life the issue of NO misuse.6,10,11 as well as liver damage. The urinary tract can as the street names already mentioned, ketamine sentence for supply.16,17,18 also become damaged leading to dysuria, is known by other names including K, Special K, Ketamine haematuria and incontinence that may require Ket, Kitkat, Vitamin K, Wonk and Green.13 Dextromethorphan Ketamine is normally sold as a grainy white or surgical intervention. Combining ketamine with Dextromethorphan is well known to pharmacists brownish powder, though it sometimes comes in other drugs is extremely dangerous, mainly Phencyclidine and their staff as a cough suppressant, but is tablet or clear liquid form. Like NO, it can be used because it is often regarded as a by Phencyclidine (phenylcyclohexyl piperidine, liable to abuse as it can have dissociative effects medicinally as an anaesthetic/analgesic and is a users. Individuals may use ketamine to induce often referred to as PCP or angel dust) is similar at high doses. This has been notable in the common controlled drug substance found within a comedown after taking a , however to ketamine in that it was developed as an where DXM, as it is sometimes

chemistanddruggist.co.uk/update-plus July 2021 | Module 1981 | Substance misuse: dissociative drugs | 2 of 3 known, is available in a significant number of similar to ketamine and PCP.19 over-the-counter cough and cold preparations, though it is also sometimes taken in tablet or Methoxetamine Take the 5-minute test online powder form. High doses can cause effects Methoxetamine has been designed and marketed 1. DXM is a common street name for 6. NO is covered under the 2006 Psychoactive as a ketamine substitute, but appears much methoxetamine. Substances Act. stronger – much as is the case for spice and True or false True or false References . It is sold in powder form, and snorted 2. Class B drugs carry a maximum 14-year 7. NO abuse can lead to vitamin B6 depletion prison sentence for supply. resulting in potentially irreversible nerve 1. Mind (2019) Dissociation and dissociative disorders (in pinches due to its strength; this is sometimes called “bumping”), absorbed sublingually, True or false damage. 2. Drug Wise (2017) Why do people take drugs? swallowed or injected. The effects are similar 3. Nitrous oxide (NO) abuse has been associated True or false 3. US National Institute on Drug Abuse (2015) What are to ketamine, but usually more intense and with significant haematuria and incontinence 8. NO is a core component of Entonox. the effects of common dissociative drugs on the brain longer lasting, and it is more likely to cause that may require surgical intervention. and body? True or false hallucinations, nystagmus (involuntary eye True or false 9. Use of ketamine among young people aged 4. NHS Digital (2018) Smoking, drinking and drug use movement), loss of balance, coordination, and among young people in England 2018 4. When snorted, ketamine will start to exert its 16-24 years was more than three times catatonia. It is a Class B drug known by several effect in roughly 20-30 minutes. greater than the national average of 0.8%. 5. Gov.uk (2019) United Kingdom drug situation 2019: street names including Rhino Ket, MXE, Moxy, True or false True or false summary Mket, Mexy and Roflcoptr.20,21 5. Ketamine is a popular choice of analgesic/ 10. Disruption of glutamate at N-methyl-D- 6. Frank (2021) Nitrous oxide For more information on common dissociative anaesthetic in conflict zones where extensive aspartate receptors leads to the dissociative drugs see: 7. Drug Science (2021) Nitrous oxide (laughing gas) monitoring is not available. effect of commonly misused drugs. • The Frank website at tinyurl.com/dissociatives1 8. Drug Wise (2021) Nitrous oxide True or false True or false • Drugwise at tinyurl.com/dissociatives2 9. Drug Watch (2016) Information sheet: nitrous oxide

10. House of Commons Library (2020) Nitrous oxide: No laughing matter? Substance misuse: dissociative drugs planned CPD example 11. Royal College of Nursing Magazines (2019) Nitrous What are you planning to learn? oxide Community pharmacy staff have a role to play in ensuring that people who access medicines, whether it be via prescription or over-the-counter (OTC), 12. World Health Organization (2016) Fact file on understand the risks associated with their use. I felt this learning would be particularly valuable given the risk for abuse of certain OTC products ketamine containing dissociative substances. I wanted to be able to recognise patients they may need additional support with substance misuse when accessing 13. Frank (2021) Ketamine pharmacy services.

14. Drug Science (2021) Ketamine How are you planning to learn it? 15. Drugs and Me (2021) Ketamine I hope to engage with the local drug and alcohol teams in our area to find out more information about referral services for drug misuse as well as

16. Rocha A, Hart N, Trujillo K (2017) Differences between whether there are additional training events for the staff at our pharmacy. I have organised a monthly team discussion on high risk medicines, with adolescents and adults in the acute effects of PCP and next month’s theme including substances for misuse including dissociative drugs. ketamine and in sensitization following intermittent administration. Pharmacology Biochemistry and Behavior. 157; 24-34. Give an example of how this learning has benefited the people using your services A young patient recently visited our pharmacy for some advice about urinary symptoms they were experiencing after drinking alcohol on nights out. 17. Frank (2021) PCP Upon further investigation, it became apparent the patient had been abusing ketamine on a regular basis during their term time at university but 18. Drug Wise (2021) PCP had been nervous initially to ask for advice about drug use. They were worried about seeing their GP, as they unsure if they would get into trouble. 19. Department of Justice/Drug Enforcement Although not an expert in the subject, my recent learning supported the structure of the consultation by discussing the risks of using ketamine, which Administration (2020) Drug fact sheet: DXM include dysuria, but also providing support for referral to the GP without concern for punitive measures as well as a number of local services for 20. Frank (2021) Methoxetamine support with drug abuse. We spoke in detail about the peer pressure associated with university and the use of drugs and how that may be encouraging them to use ketamine. Although this is not the end point for the patient, I felt confident that my knowledge of drug misuse and consultation skills 21. Drug Wise (2021) Methoxetamine allowed them to open up about the drug use and to not be afraid to access specialist services for support upon leaving the pharmacy.

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