Club drugs are substances commonly used at nightclubs, music festivals, raves, and dance parties; to enhance social intimacy and sensory stimulation. The most widely used club drugs are 3,4-methylenedioxymethamphetamine (MDMA), also known as ecstasy; gamma-hydroxy butyrate (GHB); flunitrazepam (Rohypnol) and ketamine (Ketalar). These drugs are popular because of their low cost and convenient distribution as small pills, powders, or liquids. Consequently, these drugs are popular among young persons who have been educated about the hazards of drug injection and the dangers of heroin, cocaine, and methamphetamine.
Club drugs usually are taken orally and may be taken in combination with each other, alcohol, or with other drugs. They are often adulterated or misrepresented. Any club drug overdose should therefore be suspected as unknown polydrug use. Persons who have adverse reactions to these are likely to consult a family physician. Toxicologic screening generally is not available for club drugs. The primary management is supportive care, with symptomatic control of excess central nervous system stimulation or depression. There are no specific antidotes except for flunitrazepam, a benzodiazepine that responds to flumazenil. Severe drug reactions can occur even with a small dose and may require critical care. Club drug overdose usually resolves with full recovery within seven hours. Education of the patient and family is essential.
Club drugs are favored over other recreational drugs, such as marijuana, lysergic acid diethylamide (LSD), methamphetamine, and opiates, because they are believed to enhance social interaction: “entactogens,” giving a sense of physical closeness, empathy, and euphoria. MDMA is structurally similar to amphetamine and mescaline (a hallucinogen). However, it is not as stimulating or addictive and is considered much less likely to cause psychosis than LSD and other hallucinogens. GHB and Rohypnol are powerful sedative/hypnotic agents. Ketamine is a dissociative anesthetic that produces a dreamy tranquility and disinhibition in small doses. Unlike opiates, these sedatives encourage sociability and seldom cause nausea.
Club drugs often have an high risk of unanticipated effects and overdose. MDMA ingestion increases the release of serotonin, dopamine, and norepinephrine from presynaptic neurons and prevents their metabolism by inhibiting monoamine oxidase. Users of MDMA describe initial feelings of agitation, a distorted sense of time, and diminished hunger and thirst, followed by euphoria with a sense of profound insight, intimacy, and well-being. To further enhance the sensory effects, users often wear fluorescent necklaces, bracelets, and other accessories, and apply mentholated ointment on their lips or spray menthol inhalant on a surgical mask. Unpleasant side effects of MDMA include trismus and bruxism, which can be reduced by sucking on a pacifier or lollipops. Adverse effects of MDMA ingestion result from sympathetic overload and include tachycardia, mydriasis, diaphoresis, tremor, hypertension, arrhythmias, parkinsonism, esophoria (tendency for eyes to turn inward), and urinary retention. However, the most troublesome potential outcome of MDMA ingestion is hyperthermia and the associated “serotonin syndrome.” Serotonin syndrome is manifested by grossly elevated core body temperature, rigidity, myoclonus, and autonomic instability; it results in end-organ damage, rhabdomyolysis and acute renal failure, hepatic failure, adult respiratory distress syndrome, and coagulopathy. MDMA ingestion directly causes a rise in antidiuretic hormone. Heat from the exertion of dancing in a crowded room coupled with the MDMA-induced hyperthermia can lead easily to excessive water intake and severe hyponatremia (low sodium). Neurologic effects include confusion, delirium, paranoia, headache, anorexia, depression, insomnia, irritability, and nystagmus, all of which may continue for several weeks.
The immediate concern with the use of club drugs, nitroprusside or similar often present with multiple drug ingestions, which may include stimulant and depressant drugs (e.g., MDMA combined with GHB or alcohol). When the predominant symptoms are controlled, the symptoms of a second underlying drug may surface. Most hallucinogens are CNS stimulants; in overdose, patients may exhibit hyperthermia, hypertension, tachycardia, anxiety and agitation. Precautions should be taken to prevent seizures. Gastrointestinal decontamination with activated charcoal and a cathartic may be useful in acute exposures if the drug was taken orally within the previous 60 minutes. Otherwise, unless a massive dose was taken, inducing emesis is seldom effective and may increase psychologic distress. Hypertension and tachycardia generally will resolve with the management of anxiety or agitation. Severe hypertension can be treated with labetalol, phentolamine, nitroprusside or similar agents. For agitation, benzodiazepines such as diazepam, lorazepam or midazolam. Hyperthermia should be treated immediately with tepid water bathing and fanning. Alkalinization of the urine, which usually is recommended for rhabdomyolysis, should be used cautiously because it reduces the renal clearance of amphetamine. The serotonin antagonists chlorpromazine and cyproheptadine appear to be effective in mild to moderate cases of serotonin syndrome.
Volatile substance misuse (VSM), defined as the deliberate inhalation of a volatile substance in order to achieve a change in mental state. Prevalence peaks early in age compared to other drug use, being highest among 12 to 15 years olds and diminishing thereafter. VSM has been linked with a number of markers of deprivation and marginalisation. Inhalant users have been found to exhibit relatively high rates of psychological disorders, including depression, anxiety, stress, anti-social personality disorder and poor self-esteem. They are disproportionately involved in petty crime and more likely than other young people to be incarcerated. It has also been linked with both co-occurring and future drug use (especially alcohol and cannabis), family alcohol dependence or other problematic drug use, childhood physical or sexual abuse, and homelessness or over-crowded housing.
Interventions can be grouped under 4 categories: 1) demand reduction—measures aiming at discouraging VSM; restricting their accessibility or by substituting products with less toxic alternatives; 2) nitrites—amyl nitrite or cyclohexyl nitrite found in room deodorizers; they do not directly affect the central nervous system and are generally used to enhance sexual experience 3) aerosols—sprays containing propellants and solvents, such as aerosol paints; 4) harm reduction—measures which reduce the risk of harm, without necessarily reducing its prevalence; and 5) law enforcement—statutory and community-based measures aimed at enforcing laws, by laws or other sanctions relating to VSM.
Evidence from community-based programs suggests that: 1) There are benefits to be derived rom adopting a regional approach, and complement in community capacity. 2) Community with specific skills in working with people who use volatile to provide support, education, advocacy and information about VSM. 3) Successful community-based interventions in remote communities require support from agencies such as police, clinics and schools, as well as community agencies and groups.
Effective community campaigns in urban and rural locations have included: 1) involvement of a range of community members and agency representatives; 2) research and consultation of VSM within the local area; 3) improvement of communication mechanisms between local service providers (for instance, police and welfare agencies); 4) community education to increase parental and worker sensitivity to the issue; 5) retailer education; and 6) targeting VSM ‘hotspots'.
Successful programs: include measures to avoid stigmatising drug users; focus on skill and capacity development; offer a range of activities including opportunities for risk-taking; offered on a flexible basis; utilise local resources and; are sustainable.