“Dealing” with Designer Street Drugs

Margaret Thompson, MD, FRCP(C)

esigner drugs refer to newly synthe- large patterns-of-use studies published by D sized fentanyl, meperidine, ampheta- public health associations and other organi- mine or other street drug derivatives that zations. Seizures of abused substances, are legal because they have not yet been reports of adverse reactions to substances classified as controlled substances (Table 1). and other factors temporarily influence A more liberal definition refers to designer these patterns. It must also be remembered drugs as “party or rave drugs,” which that marijuana, cocaine and heroin still include 3,4-methylenedioxymethampheta- remain popular drugs. mine (MDMA or ecstasy), gamma- MDMA is the prototypal hydroxybutyrate (GHB) and ket- amine. This definition also includes substances, such as - he dose needed to achieve B (i.e., Eve) and Tthe “K-hole” is dangerously close (i.e., Foxy and to that which induces respiratory alpha-methyl-). Raves are large dance parties depression. held in venues that are meant to be alcohol free. Access to water, wash- available in the urban community. Table 2 rooms and adequate ventilation may be lim- provides a list of common street names for ited, often causing conditions of excessive designer street drugs. Ecstasy is available environmental heat. Rave-goers often abuse as tablets with variable concentrations of substances for their , euphoric or MDMA per tablet with an average of 50 mg hallucinogenic effects. to 150 mg. There is no quality assurance for Cyclic enjoyment of these substances drugs on the street, so it is possible that often occurs, as evidenced by some of the there are other psychologically active

The Canadian Journal of Diagnosis / October 2005 89 Table 1 agents substituted for or added to the Scheduled drugs in Canada MDMA, as well as excipients. (Adapted from the Controlled Drug and Substances Act, 1996) Manifestations of toxicity may be from any of these substances, in addition to the route of exposure. Schedule I substances Amphetamines, and derivatives Amphetamines may act by and analogues, cocaine and derivatives, PCP and fentanyl derivatives, unless enhancing , norepinephrine specifically excluded in the Act. and outflow. The usual

Schedule II substances , its preparations, derivatives presentation of toxicity is of the sym- and synthetic preparations, unless pathomimetic toxidrome (Table 3) specifically exluded. but, in its severe form, the presenta- Schedule III substances , methaqualone, LSD tion may mimic the serotonin syn- (and similar tryptamines), psilocybin, drome. Complications of this toxicity mescaline, flunitrazepam, GHB and could include rhabdomyolysis, renal . failure, disseminated intravascular Schedule IV substances Barbiturates, their salts and derivatives, coagulation and death. Aggressive glutethimide, ethchlorvynol, supportive care is the mainstay of meprobamate, benzodiazepines and anabolic steroids. treatment. Hyperpyrexia is predictive of death; aggressive cooling meas- Schedule V substances Propylhexedrine ures are most important to prognosis. Schedule VI substances Several substances that would be GHB is a clear liquid with a slightly precursors to other scheduled salty taste in its pure form. Other sub- substances or would be chemicals used in the manufacturing of other scheduled stances, such as gamma-butyrolactone substances. (GBL), a solvent, 1,4-butanediol and gamma-valerolactone (GVL) are sold Schedule VII/VIII Specific amounts of cannabis substances and cannabis resin only. as natural sleep supplements, are pre-

PCP: Phencyclidine cursors to GHB and are metabolized to LSD: diethylamide GHB in vivo. GHB: Gamma-hydroxybutyrate

Table 2 Common street names for designer drugs

Category Chemical Street name

Amphetamines 2C-B Eve MDMA Ecstasy, X, XTC, E Methamphetamine Crystal, crank, ice, meth, speed PMA Death

GHB G, Grevious bodily harm, liquid E, liquid X

Ketamine Special K, “K”, kay, Vitamin K

Tryptamines Alpha-methyl-tryptamine AMT 5-methoxy-diisopropyl-tryptamine Foxy, Foxy-methoxy

2C-B: 4-bromo-2,5-dimethoxyphenethylamine PMA: Paramethoxyamphetamine MDMA: 3,4-methylenedioxymethamphetamine GHB: Gamma-hydroxybutyrate

90 The Canadian Journal of Diagnosis / October 2005 GHB is an endogenous substance and a precursor that binds to gamma-aminobutyric acid type B receptors, the main central inhibitory neurotransmitter. At low doses, GHB is an amnestic. As doses increase, the effect is of euphoria. Doses greater than 50 mg/kg would cause unconsciousness with bradypnea with otherwise normal vitals. Careful atten- tion to the airway and ventilatory status will support these patients until the GHB is metabolized. These patients have no long-term sequelae unless there has been prolonged res- piratory depression, ischemic neurologic damage and/or aspiration. Sudden cessation of GHB use by a dependent individ- ual can cause severe withdrawal syndrome that mimics alcohol withdrawal. Withdrawal onset is rapid (as GHB is a short-acting substance) and often prolonged, requiring benzodiazepine and sometimes, barbituate sedation at high doses for many days.

yperpyrexia is predictive of Hdeath; aggressive cooling measures are most important to prognosis.

Ketamine is an anaesthetic used in doses of 2 mg/kg intravenously in children, severe asthmatics and in veterinary medicine. It is a popular drug for its dissocia- tive properties. Its action is similar to phencyclidine, but its duration of action is shorter. Some ravers strive for the “K-hole,” where one feels detached from their environ- ment and looking in. The dose needed to achieve this state is dangerously close to that which induces respira- tory depression. Symptoms of ketamine overdose are of mild sympathomimetic stimulation with respiratory depression. Emergence from ketamine anaesthetic and abuse states can produce an undesirable delirium with a disturbing psychosis. Finally, the newer substances, 2C-B (4-bromo-2,5- dimethoxyphenethylamine), and Foxy (5-methoxy-diiso- Designer Street Drugs

propyl-tryptamine) and AMT (alpha- Table 3 methyltryptamine) are hallucinogenic Common toxidromes and associated symptoms amphetamines and tryptamines respec- tively. Their use is low, but reportedly Toxidrome Associated Symptoms increasing. Their effects are closer to that Sympathomimetic Diaphoresis, mydriasis, tachycardia, of mescaline; hallucinations are often hypertension, hyperpyrexia, irritability, seizures characterized as visual distortions as Alcohol or - Diaphoresis, mydriasis, tachycardia, compared to true visions. The trypta- hypnotic withdrawal hypertension, hyperpyrexia, tremors, seizures, mines, in particular, are chemically relat- hallucinations ed to ergotamines and serotonin and Serotonin syndrome In the setting of use/abuse of serotonergic cause significant gastrointestinal upset, agent(s): D Mental status changes include: which can deter repeated use. x - Irritability, agitation, disorientation, seizures, hallucinations, insomnia, drowsiness, lethargy, coma Neuromuscular effects include: Dr. Thompson is an Assitant Professor of Medicine, - Ocular or myonclonus, hyperreflexia, University of Toronto, and the Medical Director, Ontario tremor, ataxia Poison Centre, Toronto, Ontario. Autonomic disturbances include: - Diaphoresis, diarrhea, tachycardia, hyperpyrexia, hypo/hypertension, mydriasis

The Canadian Journal of Diagnosis / October 2005 93