Club Drugs - Pediatrics House Staff

Club Drugs
Arash Anoshiravani, M.D. and
Seth Ammerman, M.D., F.S.A.M.
“Club drugs” refer to a group of mind-altering substances with different effects and from
different drug classes that are typically used
in nightclub, party, or rave settings. 2 They are
all typically used to enhance or intensify social
activities and experiences. 1 The National Institute on Drug Abuse (NIDA) in the US has
labeled methamphetamine, MDMA (ecstasy),
ketamine, LSD (D-lysergic acid diethylamide),
gamma-hydroxybutyrate (GHB), and flunitrazepam (rohypnol) as “club drugs.” 3 Of these,
MDMA and LSD are the most commonly used
in the 16-23 year old age group in the United
States.4 In addition, other drugs such as phencyclidine (PCP), inhaled nitrous oxide, and sildenafil (viagra) have also gained popularity within
similar settings. Pediatricians treating adolescents and young adults should be familiar with
these drugs, as they have increased in popularity
in the last decade, have serious and often longterm consequences, and are often difficult to
identify. This article will provide an overview of
the most common club drugs, their typical use
and effects, short-and long-term adverse effects,
and finally general management approaches in
the acute and outpatient settings.
Background
The popular use of club drugs was first noted in
England during the early 1980s. Young people
began experimenting with various substances
in order to enhance their experiences of pleasure, wellness, and connectedness at large parties and social events.1,2,5 As the popularity of
large, often secretly organized parties known
as “raves” increased, so did the availability and
prevalence of these substances. Their popularity was bolstered by their relative low cost,
easy distribution in the form of pills, powders,
or liquids, and their perceived safety among
their target populations compared to heroin,
cocaine, and other “hard” drugs.2
By the early 1990s, the use of “club
drugs” had spread to the rest of Europe and
the United States, and young people had easy
access to them at nightclubs, raves, and rock
concerts in major metropolitan areas throughout the US. Studies have suggested that methamphetamine and MDMA may become the
new worldwide drug epidemic, with methamphetamine being the most widely available
and used club drug in the world.6 Concerning
prevalence in the United States, the National
Survey of Drug Use and Health, conducted by
the Substance Abuse and Mental Health Services Administration, revealed that in 2004
approximately 20% of adolescents between the4
ages of 16 and 23 had ever tried a club drug.
Over 80% of these youth had used three or
more different club drugs. And virtually all of
these youth also used other substances such as
alcohol or marijuana. In California, looking at
MDMA and LSD as examples, the 10th Biennial California Student Survey revealed that
in 2003-2004 approximately 5% of 12th grade
students had used MDMA in the past 6 months.
In 2001-2002, LSD use was at 1%, 73%, and
5% in grades 7, 9, and 11 respectively. So club
drug use starts as young as ages 12 or 13, with
prevalence gradually increasing throughout the
adolescent and young adult years.
As the use of these and other club drugs
has spread and increased, the incidence of
negative outcomes has also increased. Emergency room visits in the United States suggest
that the prevalence of club drug use increased
substantially among those receiving
emer8
gency care between 1994 and 1999. MDMArelated deaths in the US increased significantly
between
1999 and 2002, up to 400% in one
9
study. Fortunately, since 2000 the emergency
department and fatality rates of all NIDAdefined club drugs has fallen in most studies,
possibly related to increased education efforts
and an accompanying increased perception of
the risks associated with these drugs among
potential users.10 11 More recent surveys suggest that there has been at least a 25% decrease
in MDMA use among teens between 2002 and
2004, and the trend continued into 2005.2
Despite these national trends, California
continues to face very high availability of club
drugs. According to the Drug Enforcement
Agency (DEA), Southern California serves
as the main entry point for most of the club
drugs imported into California from around the
world. In addition, rural sites in Northern California continue to produce a large proportion
of the LSD and methamphetamine available in
the state.
Club drugs can be divided into four general
categories: 1) central nervous system stimu-
lants, 2) dissociative anesthetics and hallucinogens, 3) central nervous system depressants
(also implicated as “date-rape” drugs), and
4) miscellaneous. These substances are often
used together or with other substances either
intentionally or unintentionally, often resulting
in multiple effects from unknown substances.24
14
This type of use has also increased the likelihood of adverse effects. The following sections
will provide brief overviews of each category
of club drug for the general pediatrician,
including drug class, mechanisms of action,
desired and undesired effects and sequelae, and
signs of acute intoxication.
Stimulants
The stimulant club drugs include methamphetamine and MDMA. This article will not focus
on methamphetamine, as it was recently highlighted in the spring 2006 edition of California
Pediatrician. These drugs generally act as central nervous system stimulants by increasing
the presynaptic release of catecholamines and
other neurotransmitters that
act on alpha-and
5
beta­adrenergic receptors. Methamphetamine,
a synthetic derivative of the stimulant amphetamine and whose production and use has
endangered many children’s and adolescents’
lives in California,
exemplifies the effects of
15
this class. The more popular MDMA (ecstasy)
while also a derivative of amphetamine, is
slightly different in its effects and uses, and
will be discussed more extensively in its role
as a club drug. 4
Initially developed as appetite suppressant in Germany in the early 1900s, MDMA
(3, 4-­methylenedioxymethamphetamine) later
became known as an “empathy agent” during
the 1960s for its ability
to break through psy2
chological defenses. It was classified as a
Schedule I drug as of 1998.16 MDMA’s neurophysiological effects stem from its ability
to increase presynaptic release of serotonin,
dopamine, and norepinephrine, as well as the
Continued on page 24
CALIFORNIA PEDIATRICIAN—FALL 2006/ 23
Photos provided by the Drug Enforcement Administration
Introduction
CLUB DRUGS Continued from page 23
inhibition of monoamine oxidase.17 The combined effect is a substantial increase of the neurotransmitters in the neuronal synapses leading
to desired effects of MDMA, including euphoria, increased energy and self­esteem, decreased
hunger and thirst, a distorted sense of time, as
well as deep feelings of insight, intimacy, and
well-being.25 While oral doses usually produce
effects within an hour, nasal inhalation of a
crushed tablet produces faster onset of action,
and effects can last up to eight hours.25 MDMA
pills are often variably contaminated with
other substances that can cause unwanted or
unpleasant side effects (often caffeine, dextromethorphan, pseudophedrine, or LSD), including hallucinations and severe agitation.2
Side effects from the MDMA itself can
include trismus and bruxism, which are often
counteracted by sucking on lollipops or pacifiers. In addition, MDMA makes attaining an
erection difficult for men, a fact apparently
driving the increased recreational use of sildenafil among youth that will be discussed below.
More serious adverse effects directly related
to MDMA include: 1) sympathetic overload
leading to tachycardia, midriasis, diaphoresis, tremor, hypertension, arrhythmias, and
urinary retention; 2) neurologic effects such
as delirium, paranoia, irritability, insomnia,
nystagmus, and depression, any of which may
last for weeks; 3) the potential for hyponatremia from excessive fluid intake in the context
of an MDMA-induced increase in antidiuretic
hormone (ADH); and perhaps most dangerous, the serotonin syndrome, leading to severe
hyperthermia, rigidity, myoclonus, autonomic
instability, acute rhabdomyolysis and endorgan damage.2, 18 In severe overdoses, death
can occur despite appropriate medical management.5, 18 Other longer-term consequences of
MDMA use may include serotonin-depletionrelated depression several days after use, as
well as cognitive and memory impairment that
can be permanent after repeated use. 2, 19
Dissociative anesthetics and hallucinogens
The dissociative anesthetics include ketamine,
phencyclidine (PCP), and nitrous oxide; the
hallucinogens include LSD, as well as some
mushrooms and cacti. The dissociative agents
produce sedation, analgesia, euphoria, and
a sense of detachment between the mind and
body.20 The hallucinogenic agents produce profound distortions in a person’s perceptions of
reality, influencing users to see images, hear
sounds, and feel sensations that do not exist;
they can also be profoundly mood altering.21
While PCP was never approved for anesthetic
use outside of the veterinary arena because of
its severe adverse effects (severe disorientation,
disturbing hallucinations, unpredictable and
often violent behavior), ketamine and inhaled
24 / CALIFORNIA PEDIATRICIAN—FALL 2006
nitrous oxide continue to be used as effective
anesthetic agents in medical and dental settings
and this section will focus on these as the most
commonly used dissociative club drugs. Even
though the hallucinogenic properties of naturally occurring mushrooms and plants have
been known in many ancient cultures and have
been used for centuries, this section will focus
on LSD as the prototypic hallucinogen and the
one most likely to be used in the recreational
setting among youth.
Originally derived from phencyclidine
during the 1960s for use as a dissociative anesthetic, ketamine was classified as a Schedule III
drug in 1999, and in the recreational setting it
is mostly diverted from human and veterinary
anesthetic supplies, as it is difficult to manufacture.2, 16 Although it is an injectable liquid
in pharmaceutical form, as a club drug ketamine has often been dried to a powder form
that is either smoked or used intranasally.20 By
inhibiting neuronal uptake of norepinephrine,
dopamine, serotonin, and by activating the
excitatory NMDA glutamate receptor channels
of neurons, ketamine produces not only dissociative anesthesia without respiratory depression, but also occasional hallucinations and
bizarre ideations, especially as its effects wear
off.2 Desired effects include pleasant feelings
of floating to sensations of separation from the
body, lasting up to an hour. More unpleasant,
or occasionally terrifying, experiences may
include severe sensory detachment that has
been described as “near­death” experiences.20
Acute intoxication and overdose is rare as the
margin of safety for the ketamine has been well
established in the medical setting, and deaths
from ketamine use alone are rare.22, 23 However, other undesired physiologic side effects
can include agitation, combativeness, muscle
rigidity and rhabdomyolysis, and palpitations
and chest pain. Longer term effects can include
memory impairment and dissociative symptoms up to three days after use.24
Nitrous oxide, also known as “laughing
gas,” is probably best known for its use in
dental surgery. This fast-acting dissociative
anesthetic comes in a colorless, slightly sweet
smelling liquefied gas form.25 In addition to its
medical uses, nitrous oxide can be used as a
propellant, and can be commonly (and legally)
found in small canisters that attach to gourmet
whipped cream dispensers. When inhaled, it
causes euphoria, giddiness (hence the name
“laughing gas”), and intense, “pulsating” auditory and visual hallucinations.23 Its onset of
action is very quick, and the effects wear off
within minutes usually. Although nitrous is not
considered addictive, users have been known
to take hit after hit of the gas until they have
either depleted their supply of the drug, their
money, or their wakefulness. Other adverse
effects include injuries from the short-term loss
of balance and coordination the drug induces
and from frostbite of the lips from the depressurization of the gas from the canisters directly
into user’s mouths.23 More serious, long-term
consequences include the anemia and neuropathy associated with B12 deficiency secondary to nitrous’ oxidation of B12, and even
death from asphyxiation in users attempting to
achieve deeper highs by using nitrous straight
from an anesthesia tank or in a confined space
(such as in a car or with a plastic bag over their
heads).23, 26 In general, inhalant use is more commonly reported in younger adolescents.27, 28 In
the recreational club drug setting, nitrous oxide
is sold either as the individual small canisters
or as nitrous-filled balloons that give users a
cheap, quick high in the rave or nightclub setting. Often these “whippits” are used in conjunction with other club drugs or while waiting
for the other substances to take effect.
LSD is the most potent hallucinogen
known, and is also the second most commonly
used club drug behind MDMA.4 Originally
synthesized in 1938, its hallucinogenic properties were not known until the 1940s. Because
it created a state so similar to psychosis in its
users, LSD began being used as a tool to study
mental illness. It is now classified as a Schedule
I drug.29 Most often LSD is sold as a piece of
paper impregnated with the substance and colorful, graphic designs. Small tablets, thin gelatin
squares, and sugar cubes with the drug are also
seen. By stimulating the sympathetic nervous
system, LSD causes tachycardia, hypertension,
papillary dilation, and a characteristic piloerection. Effects begin within thirty to ninety
minutes of oral ingestion of LSD and can last
as long as 12 to 14 hours.29, 30 Its effects can be
unpredictable, often influenced by the personality, mood, and expectations of the user, as well
as the physical environment in which the drug
is used.29 Desired effects of the drug include a
distorted sense of time and space, as well as the
accompanying hallucinations, illusions, and distortions in sensation (“hearing colors,” “seeing
sounds”).30, 31 Undesirable or adverse effects can
include “bad trips” with acute anxiety reactions
and a sense of paranoia. Longer term effects
include “flashbacks” that can occur days to
even months after last LSD use, as well as an
“unmasking” of depression.30
Depressants and “date-rape” drugs
The depressant club drugs include gammahydroxybutyric acid (GHB) and flunitrazepam
(rohypnol). They both work through the GABA
receptor system to inhibit neuronal excitation
and cause varying degrees of central nervous
system depression. While their recreational use
will also be discussed below, they have also
gained notoriety in the past several years for
their use as “date-rape” drugs.
Gamma-hydroxybutyric acid (GHB) was
initially synthesized in 1960s in Europe as an
anesthetic, only later to be used as a nutritional
supplement for body-builders and subsequently
during the last decade as a recreational drug.32
It was initially banned in US in 1990 for nonprescription use because of its side effects,
including uncontrolled movements and respiratory and nervous system depression, and
abuse potential, and was subsequently classified as a Schedule I substance in 2000 by the
FDA.32 GHB’s neurological depressant effects
result from its derivation from the CNS inhibitory neurotransmitter GABA. At low ingested
doses, it causes euphoria and dizziness; hypotonia, amnesia, and coma occur with increasing
doses. An ingested dose causes effects within
15-30 minutes, peaking between 20-60 minutes.
Other effects include hypothermia, bradycardia,
agitation and uncontrolled limb flailing.2 The
the blood of younger people who present with
drug-induced coma.35, 36
Flunitrazepam (brand name Rohypnol)
is a rapid-acting, potent benzodiazepine that
is widely used throughout Europe and Latin
America for pre-operative anesthesia and sedation.37 Like its relatives in the benzodiazepine
class, this drug depresses CNS function through
the GABA-ergic system. It gained notoriety in
the US in the 1990s for recreational use and as
a “date-rape” drug. It has been classified as a
Schedule IV drug since 1984, making its use
and importation into the country illegal.16, 38 At
low doses, flunitrazepam decreases anxiety,
inhibitions, and muscle tension significantly
more powerfully than diazepam (valium), often
within 30 minutes after ingestion. At higher
The diagnosis and treatment of the acute and long-term effects of club drugs can
be particularly challenging.
use of GHB with another CNS depressant such
as alcohol can greatly potentiate both of their
effects, and since dosage and strength of the
drug solution are often unknown, overdoses are
relatively common. When severe, overdoses can
be characterized by seizures, coma, CheyneStokes respiration, and even death. Chronic use
can lead to dependence, withdrawal characterized by insomnia, anxiety and tremor, and even
untreatable psychosis.2
In the recreational setting, GHB has been
used for its “high,” as well as for its amnestic effects, especially when used in conjunction with other drugs such as alcohol.4, 32 This
latter scenario has led to increased concern
about GHB’s use in drug-facilitated assault.
Although most of GHB use for this purpose
is anecdotal, some researchers have suggested
that perhaps a large percentage of drug-induced
acquaintance rapes are mistakenly singly
attributed to alcohol use, when GHB may have
been involved as well.33, 34, 35 The drug is often
produced in amateur home labs and sold as a
powder or dissolved in water to form a colorless, odorless, slightly salty liquid that is relatively easy to conceal in a flavored or alcoholic
drink.32 If there is suspicion that GHB may
have been involved in an acute intoxication or
a date rape, blood and urine must be collected
within 12 hours of time of likely ingestion, and
special gas chromatography-mass spectrometry with selected ion monitoring must be run
to detect GHB, as typical toxicology screens
do not identify the drug. Given the difficulty
in definitive identification and the victims’
amnesia for any relevant events, it is quite possible that GHB is being used in a larger number
of rape cases than has been documented, and
some case series suggest that GHB may be
the second most common drug detected in
doses, the drug causes anterograde amnesia,
lack of muscle control, and unconsciousness,
with a peak effect at two hours after ingestion and lasting up to 12 hours.2, 22 Effects are
potentiated with alcohol or other sedatives,
and adverse effects include hypotension, dizziness, confusion, visual disturbances, urinary
retention, and aggressive behavior.37 Chronic
use also causes dependence, and withdrawal
symptoms include headache, anxiety, restlessness, muscle pain, numbness and tingling in
extremities, and increased seizure potential.2
In the recreational setting, flunitrazepam, like
GHB, has been implicated in drug-induced
rapes throughout the country, with most confiscations of the drug occurring in three states:
California, Texas, and Florida.37 The combination of flunitrazepam’s use in very small
doses and its very rapid clearance from users’
systems make its detection on standard drug
screens difficult, thus requiring more specialized laboratory tests described with GHB.37
Miscellaneous
It is worth noting that in recent years, the use
of sildenafil (Viagra) has increased among
youth, particularly in the setting of club drug
use. The earliest data has come from studies
of homosexual young men, particularly from
urban settings in Great Britain and the US.39, 40,
41 As previously described, MDMA in particular tends to enhance feelings of intimacy and
closeness, while simultaneously making it more
difficult for men to achieve erections and both
men and women to experience orgasms. As a
result, experimentation began with a combination of MDMA and sildenafil (“sexstasy”) in
order to create a synergistic effect.42 In the gay
population, the combined use of these drugs is
associated with increased risky sexual behav-
iors. Other than a potential increase in sexually
transmitted disease rates, adverse effects of recreational Viagra use in the club drug setting also
includes priapism and the potential physiologic
and anatomic damage that can accompany erections that last more than several hours.39 Currently, little reliable data is available about the
combined use of sildenafil and club drugs in the
adolescent population.
Management
The settings in which pediatricians may
encounter club drugs include outpatient visits
or during an acute intoxication. For most
patients, routine outpatient management will
most likely consist of adequate screening for
and accurate education about club drugs. In
particular a thorough age­tailored HEADSSS
assessment can provide clues for a patient’s
risk factors for using these substances. Youth
living in urban environments describing
attending frequent, large parties are at particular risk for exposure to and use of club drugs.
Substance histories should ask about tobacco,
alcohol, and marijuana use, as well as screen
specifically for exposure to and use of the club
drugs described above.
While abstinence is clearly the safest and
most health-promoting choice when it comes to
club drugs, pediatricians can also effectively use
a harm reduction model in approaching youth
who have used mind-altering substances in the
past. For patients who are exposed or using—or
have friends or family members who are—a
special effort to provide accurate information
about the effects of these substances, their often
unknown other ingredients, and their associations with other health-compromising problems
such as sexually transmitted infections and
accidental injuries should be provided. Young
women, in particular, need to know about the
risk for drug-­induced rapes in party settings
where they are not pouring their own drinks and
do not know the source of the substances they
might be ingesting. Homosexual youth should
be made aware of the risks of contracting HIV
and other STDs in the inhibition-free context of
parties where club drugs are readily available.
Finally, pediatricians should pay special attention to addressing the problem of multiple drug
use within the party and club settings, as such
“cafeteria”-style use substantially increases the
risks of adverse effects, overdose, and other
dangerous situations.43
The diagnosis and treatment of the acute
and long-term effects of club drugs can be
particularly challenging. Because of the illicit
nature of the drugs and the prevalence of polysubstance use, patients (or their friends) are
often unwilling or unable to provide helpful
information. In acute overdose situations, they
may not be capable of communicating coherContinued on page 28
CALIFORNIA PEDIATRICIAN—FALL 2006/ 25
CLUB DRUGS Continued from page 25
Hurricane Katrina
ently, or at all. As a result, a general approach
is needed in evaluating a previously healthy
adolescent or young adult with a history of an
acute
Clydemental
Wesp,status
M.D. change, as well attending a
party, nightclub, or other social event.44
As always, assessing and stabilizing the
patient’s ABCs and establishing intravenous
access when appropriate are the first step in
the assessment and management of an acutely
altered, possibly intoxicated patient. Monitoring vital signs can provide clues as to the
type of substance (eg. tachycardia, hypertension, hyperthermia with stimulants; bradycardia, respiratory depression, hypotension with
depressants); however, with polysubstance use
more the rule than the exception in club settings, the signs and symptoms may not provide
a complete picture. In addition to the routine
serum chemistries, osmolality, myoglobin,
lactic acid, and serum and urine toxicology
screens available at most labs, physicians
should obtain and store extra blood and urine
for more specialized gas chromatography-mass
spectroscopy or high pressure liquid chromatography studies that are more sensitive and
specific for most of the club drugs discussed
in this article. The sooner these samples are
drawn, the more helpful their results will be,
especially when there is suspicion of substances
such as GHB that have very fast clearance.
Central nervous system pathology should also
be considered and evaluated for intracranial
mass or bleed and infection with head CT and
lumbar puncture, respectively. Finally, pediatricians should consider the possibility that a
patient is withdrawing from a substance(s),
perhaps while simultaneously intoxicated with
a different one. Given the complexity of such
situations, pediatricians can seek help from
their colleagues at their local Poison Control
Center, Emergency Department, or ICU, where
prioritization decisions can be made jointly
about the severity and time course of management of each condition. 44
Conclusion
The use of club drugs is relatively common
among adolescents and young adults. Patients
who go to raves or similar kinds of parties, or
who go “clubbing,” are particularly likely to be
exposed to club drug use or to use club drugs
themselves. When taking a substance use history, pediatricians should screen for the use of
these drugs in addition to the more widely used
drugs such as alcohol, tobacco, and marijuana.
Providing accurate information to patients
about effects and side effects of these substances will help patients better understand the
potential dangers of club drug use. Additionally, by discouraging taking multiple drugs at
the same time, morbidity and even mortality
can be decreased in club drug users. Finally,
having a high index of suspicion for the use of
club drugs in the setting of a previously healthy
young person with acute mental status change
can facilitate early, appropriate management of
an acutely intoxicated club drug user.
WEB RESOURCES
Substance Abuse and Mental Health Administration:
www.samhsa.gov National Institute of Drug Abuse: www.
nida/nih.gov California: www.ca.gov (type club drugs in
search box)
REFERENCES
1. Parks KA, Kennedy CL. Club drugs: reasons for and
consequences of use. Journal of
psychoactive drugs. 2004; 36 (3): 295-302.
Street names for club drugs
MDMA
Crank, chalk, crystal, fire, glass, go fast, ice, meth,
speed 45
Ecstacy, adam, XTC, hug, beans, love drug, disco
biscuit, hug drug, go, X, clarity, lover’s speed, peace,
STP 3, 16, 45, 46
Dissociative anesthetics / hallucinogens
Ketamine
Special K, vitamin K, cat valium, K, jet, super acid
Phencyclicine (PCP)
Angel dust, boat, hog, love boat, peace pill 45
Nitrous oxide
Laughing gas, whippets, buzz bomb, Whip-Its 48, 49, 50
D-Lysergic acid diethylamide
Acid, sunshine, boomers, microdol 51
16, 47
“Date rape” drugs
GHB
Flunitrazepam (rohypnol)
Liquid ecstasy, soap, easy lay, vit-G, Georgian home
boy, goop, grievous bodily harm, max 16, 38
Forgetme pill, Mexican Valium, R2, Roche, roofies,
roofinol, rope, rophies, roach 45, 52
Miscellaneous
Sildenafil (viagra)
Sexstasy, trail mix 53
28 / CALIFORNIA PEDIATRICIAN—FALL 2006
AAP-California,
District IX Report
Am Fam Physician. 2004 Jun 1;69(11):2619-26.
3. www.nida.nih.gov/DrugPages/Clubdrugs.html, accessed
6/30/06
4. Wu LT, Schlenger WE, Galvin DM. Concurrent use of
methamphetamine, MDMA, LSD, ketamine, GHB, and
flunitrazepam among American youths. Drug and alcohol
Burton 2006;
Willis,
M.D.
and Kris Calvin,
dependence.
84(1):
102-113.
M.A.
5. Graeme KA. 2000. New drugs of abuse. Emergency
medicine clinics of North America 18 (4):625-636.
6. United Nations Office of Drugs and Crime, 2003.
Ecstasy and amphetamines global survey 2003. United
Nations Office of Drugs and Crime, United Nations,
New York, NY. Accessed on August 12, 2006 from:
http://www.unodc.org/pdf/publications/report_ats_200309-23_1.pdf.
7. www.safestate.org/documents/final-CSS03Tables.pdf,
accessed 8/13/2006.
8. Office of Applied Studies. Club drugs, 2002 update. The
DAWN Report. Accessed on August 12, 2006 from: www.
oas/samhsa.gov/2k4/slubdrugs/clubdrugs.pdf.
9. Patel MM, Wright DW, Ratcliff JJ, Miller MA. Shedding new light on the “safe” club drug:
methylenedioxymethamphetamine (ecstasy)-related fatalities. Acad Emerg Med. 2004; 11:208-210.
10.Yacoubian GS, Boyle C, Harding CA, Loftus EA.
2003. It’s a rave new world: estimating theprevalence and
perceived harm of ecstasy and other drug use among club
rave attendees. Journal of drug education 33 (2): 187-196.
11.White B, Degenhardt L, Breen C, Bruno R, Newman J,
Proudfoot P. Risk and benefitperceptions of party drug use.
Addictive behaviors. 2006; 31(1): 137-14.
12.Partnership for a Drug Free America. The Partnership
Attitude Tracking Survey (PATS): Teens grades 7-12. 2005.
Accessed 8/12/06 from: www.drugfree.org/files/full_teen_
report.
13.www.dea.gov/pubs/states/california.html, accessed
8/12/06.
14.The National Drug Control Strategy: 2000 annual
report. Washington, DC: Office of National Drug Control
Policy, 2000. Accessed on August 12, 2006 from: http://
www.ncjrs.gov/ondcppubs/publications/policy/ndcs00/.
www.ncjrs.gov/ondcppubs/publications/policy/ndcs00/.
15.Agnew A, Ammerman SD. Methamphetamine and the
pediatric patient. California Pediatrician. Spring 2006: 12-20.
16.www.whitehousedrugpolicy.gov/drugfact/club/index.
html, accessed 6/30/06
Stimulants
Methamphetamine
2. Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), Rohypnol, and ketamine.
17.White SR, Obradovic T, Imel KM, et al. The effects of
methylenedioxymethamphetamine (MDMA, ecstasy) on
monoaminergic neurotransmission in the central nervous
system. Prog Neurobiol. 1996; 49:455-479.
18.Schwartz RH, Miller NS. MDMA (ecstasy) and the
rave: a review. Pediatrics. 1997; 100:705-708.
19.Gouzoulis-Mayfrank E, Daumann J. Neurotoxicity
of methylenedioxyamphetamines (MDMA; ecstasy) in
humans: how strong is the evidence for persistent brain
damage? Addiction.2006;101(3):348-61.
20.http://www.nida.nih.gov/ResearchReports/Hallucinogens/halluc4.html, accessed 8/15/2006.
21.http://www.drugabuse.gov/ResearchReports/Hallucinogens/halluc2.html#dissoc
22.Gable RS. 2004. Acute toxic effects of club drugs.
Journal of psychoactive drugs 36 (3): 303­313.
23.www.wisconsinpoison.org-mnpoison-pdfs-Raves-ClubDrugs.pdf, accessed August 12, 2006.
24.Curran HV, Morgan C. Cognitive, dissociative and psychotogenic effects of ketamine in recreational users on the
night of drug use and 3 days later. Addiction (2000) 95(4),
575-590.
25.http://www.cganet.com/N2O/, accessed 8/10/06
26.http://www.cganet.com/N2O/factsht.asp, accessed
8/12/06
27.http://www.whitehousedrugpolicy.gov/drugfact/inhalants/index.html, accessed August 12, 2006.
28.Kurtzman TL, Otsuka KN, Wahl RA. Inhalant abuse
by adolescents. Journal of adolescent health. 2001; 28 (3):
170-180.
29.http://www.whitehousedrugpolicy.gov/drugfact/hallucinogens/index.html, accessed 8/14/06.
30.Greene JP, Ahrendt D, Stafford EM. Adolescent abuse
of other drugs. Adolescent medicine clinics. 2006; 17 (2):
283-318.
31.http://www.dea.gov/pubs/abuse/8-hallu.htm#LSD,
accessed 8/14/06.
32.Snead OC III, Gibson KM. γ-Hydroxybutyric acid. N
Engl J Med. 2005; 352:2721-2732.
33.Slaughter L. Involvement of drugs in sexual assault. J
Reprod Med. 2000; 45:425-30.
34.Varela M, Nogue S, Oros M, Miro O. 2004. Gamma
hydroxybutirate use for sexual assault.
Emergency medicine journal 21 (2): 255-256.
35.Jamieson MA, Weir E, Rickert VI, Coupey SM. 2002.
Rave culture and drug rape. Journal of
pediatric and adolescent gynecology 15 (4): 251-257.
36.Miró O, Nogué S, Espinosa G, To-Figueras J, Sánchez
M. Trends in illicit drug emergencies:
the emerging role of gamma-hydroxybutyrate. J Toxicol
Clin Toxicol. 2002; 40:129-35.
37.Editors: Keany JE, Talavera F, Anker A. Club Drugs.
Accessed on June 30, 2006 from:www.emedicinehealth.com.
38.www.nida.nih.gov/infofacts/rohypnolghb.html, accessed
6/30/06
39.Kim AA, Kent CK, Klausner JD. Increased risk of HIV
and sexually transmitted disease transmission among gay
or bisexual men who use Viagra, San Francisco 2000-2001.
AIDS. 2002; 16(10):1425-8.
40.McCambridge J, Mitcheson L, Hunt N, Winstock A.
The rise of Viagra among British illicit drug users: 5-year
survey data. Drug Alcohol Rev. 2006 Mar;25(2):111-3.
41.Fernández MI, Perrino T, Collazo JB, Varga LM, Marsh
D, Hernandez N, Rehbein A, Bowen GS. Surfing New Territory: Club-Drug Use and Risky Sex Among Hispanic Men
Who Have Sex with Men Recruited on the Internet. Journal
of Urban Health: Bulletin of the New York Academy of
Medicine. 2005; 82(1S1): i79-i88.
42.http://www.mdma.net/sexstasy/index.html, accessed
8/14/2006.
43. Tong T, Boyer EW. 2002. Club drugs, smart drugs,
raves, and circuit parties: an overview of
the club scene. Pediatric emergency care 18 (3): 216-218.
44. Ricaurte GA, McCann UD. Recognition and management of complications of new recreational drug use. The
Lancet. 2005. 365:2137-2145.
45.www.drugabuse.gov/DrugPages/DrugsofAbuse.html,
accessed 6/30/06
46.www.nida.nih.gov/pdf/infofacts/MDMA06.pdf,
accessed 6/30/06
47.www.nida.nih.gov/pdf/infofacts/clubdrugs06.pdf,
accessed 6/30/06
48.http://www.whitehousedrugpolicy.gov/publications/pdf/
inhalants%5Ffactsheet.pdf
49.http://www.whitehousedrugpolicy.gov/drugfact/inhalants/index.html
50.http://www.azprevention.org/In_The_News/Newsletters/
newsletter_article_2.htm
51. www.justthinktwice.com/drugfacts/lsd.com, accessed
8/12/06
52. www.nida.nih.gov/infofacts/rohypnolghb.html, accessed
6/30/06
53. http://www.cesar.umd.edu/cesar/drugs/ecstasy.asp,
accessed 8/14/06.
Contributors
Robert Adler, M.D.,
M.S., Ed.
Photo Quiz
Dr. Adler is the editor of
California Pediatrician. He
is the Vice Chair and Professor of Pediatrics at the Keck
School of Medicine of the
University of Southern California and the Associate Chair of the Department of Pediatrics
and Academic Affairs and Director of Medical
Education at Childrens Hospital Los Angeles.
Seth Ammerman, M.D.,
F.S.A.M.
Club Drugs
Dr. Seth Ammerman is
Clinical Associate Professor, Department of Pediatrics, Division of Adolescent
Medicine, Stanford University. Dr. Ammerman
is chair of the AAP-CA Chapter One Substance
Abuse Committee and an adolescent medicine
specialist. He is medical director of the Adolescent Outreach Project, a mobile clinic program
sponsored by Packard Children’s Hospital at
Stanford that provides comprehensive primary
care health services to homeless and uninsured
adolescents ages 12-24.
Arash Anoshiravani,
M.D.
Club Drugs
Dr. Anoshiravani has been
interested in adolescent
health, health promotion,
and education since his own
adolescence. After medical
school, he completed his training in pediatrics
at the Lucile Packard Children’s Hospital at
Stanford, and worked as a pediatric hospitalist for several years subsequently. He is now a
second-year fellow in adolescent medicine at
the Stanford School of Medicine, and is interested in the care of previously and currently
detained youth.
Kris Calvin, M.A.
District Report
Ms. Calvin is Executive
Director of AAP-CA. Prior
to that, she was Manager
of Maternal and Child
Health Policy at the California Medical Association. Trained in health economics and child
psychology and development at Stanford and
UC Berkeley, Ms. Calvin staffs legislative and
policy activities for the District.
Robert Hartman, M.D.
Photo Quiz
Dr. Hartman is a Boardcertified Pediatric Dermatologist. He did his
residency in Dermatology
at Yale University and was
trained by the late Sidney
Hurvitz M.D. Dr. Hartman is a Clinical Associate Professor in the Department of Dermatology at USC School of Medicine and attends
the pediatric dermatology clinic at CHLA. Dr.
Hartman passed the Pediatrics Dermatology
Boards, which were given for the first time in
2004.
Mika Hiramatsu, M.D.
Annual Leadership Forum
Report
Dr. Hiramatsu is a pediatrician in general practice in
Castro Valley, California.
She completed her undergraduate education at UC
Berkeley, medical school at UC San Francisco
and residency in pediatrics at Children’s Hospital Oakland. Dr. Hiramatsu is District IX
representative to the AAP Annual Leadership
Forum, immediate past president of the California AAP Chapter 1, and chair of the editorial advisory board of AAP News. She lives in
Northern California and has two sons.
Beverly Isman, R.D.H.,
M.P.H., E.L.S.
California First Smiles
Project: Resources for
Pediatricians
Fluoride Varnish: A New
Opportunity to Help
Prevent Tooth Decay in Young Children
Beverly Isman is a private dental public health
consultant, currently working with various First
Smiles projects. She was a Public Health Advisor with the Indian Health Service; Director of
the Division of Dental Health, Maine Bureau
of Health; Associate Professor in Applied Dentistry at the University of Colorado School of
Dentistry; and Chief of Dental Hygiene, JFK
Child Development Center at the University
of Colorado Health Sciences Center. She has
worked extensively with community-based programs for young children, children and adults
with special health care needs, migrant families,
elders, and homeless families.
Robert A. Jacobs,
M.D., M.P.H.
When I was Young: The
Usual Childhood Illnesses
Head of the Division of General Pediatrics and the USC
University Center for Excellence in Developmental Disabilities (UCEDD),
Continued on page 30
CALIFORNIA PEDIATRICIAN—FALL 2006/ 29