CHAPTER 65: COCAINE AND OTHER COMMONLY ABUSED DRUGS

The abuse of cocaine and other psychostimulants reflects a complex interaction between the pharmacology of the drug, the personality and expectations of the user, and the environmental context in which the drug is used¹. Polydrug abuse involving the concurrent use of several drugs with different pharmacologic effects is increasingly common. Sometimes one drug is used to enhance the effects of another, as with the combined use of cocaine and nicotine, benzodiazepines and methadone, or cocaine and heroin in methadone-maintained patients. Some forms of polydrug abuse, such as the combined use of IV heroin and cocaine, are especially dangerous and account for many hospital emergency room visits.

Chronic cocaine and psychostimulant abuse may cause a number of adverse health consequences and may exacerbate preexisting disorders such as hypertension and cardiac disease. The combined use of two or more drugs may accentuate medical complications associated with abuse of one drug. Chronic drug abuse is often associated with immune system dysfunction and increased vulnerability to infections, including risk for HIV infection. In addition, concurrent use of cocaine and opiates (the “speedball”) is frequently associated with needle sharing by IV drug users. IV drug abusers continue to be the largest single group of persons with HIV infection in several major metropolitan areas in the United States as well as in many parts of Europe and Asia.

Stimulants and hallucinogens have been used to induce euphoria and alter consciousness for centuries. Cocaine and marijuana are two of the most commonly abused drugs today. Synthetic variations of marijuana and a variety of hallucinogens have become popular recently, and new drugs are continually being developed. This chapter describes the subjective and adverse medical effects of cocaine, marijuana, and lysergic acid diethylamide (LSD), as well as methamphetamine, 3,4-methylenedioxy-N-methamphetamine (MDMA), synthetic cathinones (bath salts), phencyclidine (PCP), Salvia divinorum, and other drugs of abuse (flunitrazepam, γ-hydroxybutyric acid [GHB], ketamine). Some options for medical management of severe adverse effects are also described.

Cocaine is a stimulant and a local anesthetic with potent vasoconstrictor properties. The leaves of the coca plant (Erythroxylum coca) contain ~0.5–1% cocaine. The drug produces physiologic and behavioral effects after oral, intranasal, IV, or inhalation/smoking routes of administration. The reinforcing effects of cocaine are related to activation of dopaminergic neurons in the mesolimbic system (Chap. 60). Cocaine increases synaptic concentrations of the monoamine neurotransmitters dopamine, norepinephrine, and serotonin by binding to transporter proteins in presynaptic neurons and blocking reuptake.

PREVALENCE OF COCAINE USE

Cocaine is widely available and is abused in virtually all social and economic strata of society. In 2012, an estimated 1.6 million persons in the United States used cocaine, and 1.1 million abused or were dependent on cocaine. Emergency room admissions involving cocaine totaled 505,224 in 2011. Cocaine abuse is prevalent in the general population and in heroin-dependent persons, including those in methadone maintenance programs. IV cocaine is often used concurrently with IV heroin in a combination called a “speedball.” This combination purportedly attenuates the postcocaine “crash” and substitutes a cocaine “high” for the heroin “high” blocked by methadone.

ACUTE AND CHRONIC INTOXICATION

There has been an increase in both IV administration and inhalation of pyrolyzed cocaine via smoking. Following intranasal administration, changes in mood and sensation are perceived within 3–5 min, and peak effects occur at 10–20 min. These effects rarely last more than 1 h. Inhalation of pyrolyzed materials includes inhaling crack/cocaine or smoking coca paste, a product made by extracting cocaine preparations with flammable solvents, and cocaine free-base smoking. Free-base cocaine, including the free-base prepared with sodium bicarbonate (crack), has become increasingly popular because of its relative high potency and rapid onset of action (8–10 seconds following smoking).

Cocaine produces a brief, dose-related stimulation and euphoria and an increase in cardiac rate and blood pressure. Body temperature usually increases following cocaine administration, and high doses of cocaine may induce lethal pyrexia or hypertension. Because cocaine inhibits reuptake of catecholamines at adrenergic nerve endings, it potentiates sympathetic nervous system activity. Cocaine has a short plasma half-life of approximately 45–60 min. Cocaine is metabolized by plasma esterases, and cocaine metabolites are excreted in urine. The brief duration of the euphorigenic effects of cocaine reported by chronic abusers is probably due to both acute and chronic tolerance. Cocaine may be used as often as two to three times per hour. Alcohol is often used to modulate both the cocaine high and the dysphoria associated with the abrupt disappearance of cocaine’s effects. A metabolite of cocaine, cocaethylene, has been detected in blood and urine of persons who concurrently abuse alcohol and cocaine. Cocaethylene induces changes in cardiovascular function similar to those of cocaine alone, and the pathophysiologic consequences of the concurrent abuse of alcohol plus cocaine may be additive.

Cocaine may cause serious medical consequences by any route of administration. The prevalent assumption that cocaine inhalation or IV administration is relatively safe is contradicted by reports of death from respiratory depression, cardiac arrhythmias, and convulsions associated with cocaine use. In addition to generalized seizures, neurologic complications may include headache, ischemic or hemorrhagic stroke, or subarachnoid hemorrhage. Disorders of cerebral blood flow and perfusion in cocaine-dependent persons have been detected with magnetic resonance spectroscopy (MRS). Inhalation of crack cocaine may lead to severe pulmonary disease due to the direct effects of cocaine and to residual contaminants in the smoked material. Hepatic necrosis may occur following chronic crack/cocaine use. Protracted cocaine abuse may also cause paranoid ideation and visual and auditory hallucinations, a state that resembles alcoholic hallucinosis.

Although men and women who abuse cocaine may report that the drug enhances libidinal drive, chronic cocaine use causes significant loss of libido and adversely affects sexual function. Impotence and gynecomastia have been observed in male cocaine abusers, and these abnormalities often persist for long periods following cessation of drug use. Cocaine abuse may produce major derangements in menstrual cycle function including galactorrhea, amenorrhea, and infertility in women and in a rhesus monkey model of cocaine self-administration. Chronic cocaine abuse may cause persistent hyperprolactinemia as a consequence of disordered dopaminergic inhibition of prolactin secretion by the anterior pituitary. Cocaine abuse by pregnant women, particularly crack smoking, has been associated with both an increased risk of congenital malformations in the fetus and perinatal cardiovascular and cerebrovascular disease in the mother. However, cocaine abuse per se is probably not the sole cause of these perinatal disorders, because maternal cocaine abuse is often associated with poor nutrition and prenatal health care as well as polydrug abuse that may contribute to the risk for perinatal disease.

Psychological dependence on cocaine, indicated by inability to abstain from frequent compulsive use, has been reported. Although the occurrence of withdrawal syndromes involving psychomotor agitation and autonomic hyperactivity remains controversial, severe depression (“crashing”) following cocaine intoxication may accompany drug withdrawal.

TREATMENT

Cannabis sativa contains >400 compounds in addition to the psychoactive substance, delta-9-tetrahydrocannabinol (THC). Marijuana cigarettes are prepared from the leaves and flowering tops of the plant, and a typical marijuana cigarette contains 0.5–1 g of plant material. The usual THC concentration varies between 10 and 40 mg, but concentrations <100 mg per cigarette have been detected. Hashish is prepared from concentrated resin of C. sativa and contains a THC concentration of between 8 and 12% by weight. “Hash oil,” a lipid-soluble plant extract, may contain THC between 25 and 60% and may be added to marijuana or hashish to enhance its THC concentration. Smoking is the most common mode of marijuana or hashish use. During pyrolysis, <150 compounds in addition to THC are released in the smoke. Although most of these compounds do not have psychoactive properties, they may have physiologic effects.

THC is quickly absorbed from the lungs into blood and then rapidly sequestered in tissues. THC is metabolized primarily in the liver, where it is converted to 11-hydroxy-THC, a psychoactive compound, and >20 other metabolites. Many THC metabolites are excreted through the feces at a relatively slow rate of clearance compared with most other psychoactive drugs.

Specific cannabinoid receptors (CB₁ and CB₂) have been identified in the central and peripheral nervous system. High densities of cannabinoid receptors have been found in the cerebral cortex, basal ganglia, and hippocampus. T and B lymphocytes also contain cannabinoid receptors, and these appear to mediate the anti-inflammatory and immunoregulatory properties of cannabinoids. A naturally occurring THC-like ligand has been identified and is widely distributed in the nervous system.

Herbal marijuana alternatives are also available. These are usually a combination of several herbs and synthetic cannabinoids. “Spice” and “K2” are among the best known, but many formulations exist, and marijuana is undetectable by the usual methods. These compounds are marketed on the Internet as containing no illegal ingredients. However a number of synthetic cannabinoids are now classified as Schedule I by the Drug Enforcement Administration due to reports of toxicity.

PREVALENCE OF USE

Marijuana is the most commonly used illegal drug in the United States. In 2012, an estimated 18.9 million people reported using marijuana within the past month. An estimated 7.2% of adolescents age 12 to 17 years reported current use of marijuana. Marijuana is relatively inexpensive and is often considered to be less hazardous than other controlled drugs and substances. Very potent forms of marijuana (sinsemilla) are widely available, and concurrent use of marijuana with other drugs such as cocaine is not uncommon. Due in part to the difficulty of detecting herbal marijuana alternatives, the prevalence of use is unknown.

ACUTE AND CHRONIC INTOXICATION

Acute intoxication from marijuana and cannabis compounds is related to both the dose of THC and the route of administration. THC is absorbed more rapidly from marijuana smoking than from orally ingested cannabis compounds. Acute marijuana intoxication may produce a perception of relaxation and mild euphoria resembling mild to moderate alcohol intoxication. This condition is usually accompanied by some impairment in thinking, concentration, and perceptual and psychomotor function. Higher doses of cannabis may produce more pronounced impairment in concentration and perception, as well as greater sedation. Although the acute effects of marijuana intoxication are relatively benign in normal users, the drug can precipitate severe emotional disorders in individuals who have antecedent psychotic or neurotic problems. Like other psychoactive compounds, both the user’s expectations and the environmental context are important determinants of the type and severity of the effects of marijuana intoxication.

As with abuse of cocaine, opioids, and alcohol, chronic marijuana abusers may lose interest in common socially desirable goals and devote progressively more time to drug acquisition and use. However, THC does not cause a specific and unique “amotivational syndrome.” The range of symptoms sometimes attributed to marijuana use is difficult to distinguish from mild to moderate depression and the maturational dysfunctions often associated with protracted adolescence. Chronic marijuana use has also been reported to increase the risk of psychotic symptoms in individuals with a past history of schizophrenia. Persons who begin marijuana smoking before the age of 17 may have more pronounced cognitive deficits and also may be at higher risk for polydrug and alcohol abuse problems in later life, but the role of marijuana in this sequence is uncertain.

The acute effects of herbal marijuana alternatives are based primarily on case reports and include anxiety, agitation, delusions, paranoia, and psychosis. The extent to which these symptoms reflect drug effects or exacerbation of an underlying psychiatric disorder is often difficult to determine.

PHYSICAL EFFECTS

Conjunctival injection and tachycardia are the most frequent immediate physical concomitants of smoking marijuana. Tolerance for marijuana-induced tachycardia develops rapidly among regular users. However, marijuana smoking may precipitate angina in persons with a history of coronary insufficiency. Exercise-induced angina may increase after marijuana use to a greater extent than after tobacco cigarette smoking. Patients with cardiac disease should be strongly advised not to smoke marijuana or use cannabis compounds.

Significant decrements in pulmonary vital capacity have been found in regular daily marijuana smokers. Because marijuana smoking typically involves deep inhalation and prolonged retention of marijuana smoke, chronic bronchial irritation may develop. Impairment of single-breath carbon monoxide diffusion capacity (Dl_CO) is greater in persons who smoke both marijuana and tobacco than in tobacco smokers.

Although marijuana has also been associated with a number of other adverse effects, many of these studies await replication and confirmation. A reported correlation between chronic marijuana use and decreased testosterone levels in males has not been confirmed. Decreased sperm count and sperm motility and morphologic abnormalities of spermatozoa following marijuana use have been reported. Prospective studies found a correlation between impaired fetal growth and development and heavy marijuana use during pregnancy. Marijuana has also been implicated in derangements of the immune system; in chromosomal abnormalities; and in inhibition of DNA, RNA, and protein synthesis; however, these findings have not been confirmed or related to any specific physiologic effect in humans. Herbal marijuana alternatives produce many of the effects of marijuana including conjunctival injection and tachycardia.

TOLERANCE AND PHYSICAL DEPENDENCE

Habitual marijuana users may develop tolerance to the psychoactive effects of marijuana, and then smoke more frequently and try to acquire more potent cannabis compounds. Tolerance for the physiologic effects of marijuana develops at different rates; e.g., tolerance develops rapidly for marijuana-induced tachycardia but more slowly for marijuana-induced conjunctival injection. Tolerance for both behavioral and physiologic effects of marijuana decreases rapidly upon cessation of marijuana use.

A distinct withdrawal syndrome has been documented in chronic cannabis users, and the severity of symptoms is related to dosage and duration of use. These symptoms typically reach their peak several days after cessation of chronic use and include irritability, anorexia, and sleep disturbances. Withdrawal signs and symptoms observed in chronic marijuana users are usually relatively mild in comparison to those observed in heavy opioid or alcohol users and rarely require medical or pharmacologic intervention. However, more severe and protracted abstinence syndromes may occur after sustained use of high-potency cannabis compounds. As yet there have been no systematic studies of tolerance and physical dependence to the herbal marijuana alternatives. The large number of synthetic cannabinoids available for combination with about 20 herbs presents a daunting challenge for analysis.

THERAPEUTIC USE OF MARIJUANA

Marijuana, administered as cigarettes or as a synthetic oral cannabinoid (dronabinol), is thought to have a number of clinically useful medicinal properties. These include antiemetic effects in chemotherapy recipients, appetite-promoting effects in AIDS patients, reduction of intraocular pressure in glaucoma, and reduction of spasticity in multiple sclerosis and other neurologic disorders. With the possible exception of AIDS-related cachexia, none of these attributes of marijuana compounds is clearly superior to other readily available therapies.

Methamphetamine is also referred to as “meth,” “speed,” “crank,” “chalk,” “ice,” “glass,” or “crystal.” Methamphetamine is a mixed-action monoamine releaser with activity at dopamine, serotonin, and norepinephrine systems. Methamphetamine was considered second only to cocaine as a drug threat to society by the U.S. Department of Justice in 2009. Hospital admissions for methamphetamine treatment more than doubled between 1998 and 2007, and young adults (age 18–25) have the highest use rates. In 2011, an estimated 439,000 people reported current use of methamphetamine in the United States, and emergency room admissions involving amphetamines/methamphetamine totaled 160,000. Persistent abuse of methamphetamine continues despite drug seizures, closures of clandestine laboratories that produce methamphetamine illegally, and an increase in methamphetamine abuse prevention programs.

Methamphetamine can be used by smoking, snorting, IV injection, or oral administration. Methamphetamine abusers report that drug use induces feelings of euphoria and decreased fatigue. Adverse consequences of methamphetamine use include headache, difficulty concentrating, diminished appetite, abdominal pain, vomiting or diarrhea, disordered sleep, paranoid or aggressive behavior, and psychosis. Chronic methamphetamine abuse can result in severe dental caries, described as blackened, rotting, crumbling teeth. Severe, life-threatening methamphetamine toxicity may include hypertension, cardiac arrhythmia or cardiac failure, subarachnoid hemorrhage, ischemic stroke, intracerebral hemorrhage, convulsions, or coma.

Methamphetamines increase the release of monoamine neurotransmitters (dopamine, norepinephrine, and serotonin) from presynaptic neurons. It is thought that the euphoric and reinforcing effects of this class of drugs are mediated through dopamine and the mesolimbic system, whereas the cardiovascular effects are related to norepinephrine. MRS studies of the brain suggest that chronic abusers have neuronal damage in the frontal areas and basal ganglia.

Treatment of acute methamphetamine overdose is largely symptomatic. Ammonium chloride may be useful to acidify the urine and enhance clearance of the drug. Hypertension may respond to sodium nitroprusside or α-adrenergic antagonists. Sedatives may reduce agitation and other signs of central nervous system hyperactivity. Treatment of chronic methamphetamine dependence may be accomplished in either an inpatient or outpatient setting using strategies similar to those described earlier for cocaine abuse.

MDMA is a derivative of methamphetamine also called Ecstasy or Molly. Reported use of MDMA in the United States has increased from 615,000 persons in 2005, to an estimated 869,000 people in 2012. Emergency ward admissions involving MDMA totaled more than 22,000 in 2011. Ecstasy is usually taken orally but may be injected or inhaled, and its effects last for 3–6 h. MDMA has amphetamine-like effects including vivid visual and auditory hallucinations and other perceptual distortions. Recent studies indicate that MDMA use is associated with cognitive and memory impairment. MDMA can induce hyperthermia and elevated blood pressure, seizures, comma, and death. Withdrawal symptoms after cessation of use may include teeth grinding, anxiety, loss of appetite, insomnia, and fever. The long-term consequences of recreational use of MDMA by young persons are poorly understood.

The rapid emergence of synthetic cathinone abuse during 2010 was accompanied by numerous reports of adverse medical and psychiatric effects, suicides, and deaths. Reports to poison centers and health agencies increased from about 300 in 2010 to over 6000 in 2011. In 2011, the Drug Enforcement Administration classified three commonly abused synthetic cathinones (mephedrone [4-methyl methcathinone], MDPV [3,4-methylenedioxy pyrovalerone], and methylone) as Schedule I compounds with no accepted medical use and a high potential for abuse. However, synthetic cathinones are readily available on the Internet as well as in convenience stores, gas stations, and head shops. These drugs are merchandised under a variety of names such as Vanilla Sky, Purple Wave, Blue Silk, White Lightening, and Snow Leopard. Regulatory constraints are evaded by labeling the products as plant food, insecticides, pond cleaner, and bath salts with the qualifier, “not for human consumption.”

Cathinone is the primary psychoactive ingredient in khat leaves. Chewing the leaves of the khat shrub (Catha edulis) produces mild stimulant and euphoric effects and remains a common practice in east Africa that has persisted for centuries. Cathinone is structurally similar to amphetamine, and mephedrone is structurally similar to methamphetamine. Cathinones, like amphetamines, inhibit dopamine, serotonin, and norepinephrine transporters to varying degrees, and this probably accounts for variations in the behavioral effects observed. The effects of cathinone derivatives are often described as similar to the effects of MDMA or Ecstasy. Synthetic cathinones can be inhaled, snorted, injected, or taken orally. These drugs may be taken repeatedly over several hours in episodes lasting for hours or days. The onset of effects after oral ingestion is relatively rapid for MDPV (15–30 min) and slightly slower for mephedrone and methylone (30–45 min). The duration of action varies from 2 to 5 or 7 h. After mephedrone inhalation, effects occur within minutes and only last for 1 h or less, but mood changes may persist for several days. Evaluation of the neurotoxic effects of prolonged synthetic cathinone abuse is just beginning, and the long-term consequences are unknown.

The reported positive subjective effects of synthetic cathinones include euphoria, improved energy, alertness, sociability, and increased sensitivity to music and other sensory experiences. The reported negative subjective effects include agitation, visual and auditory hallucinations, anxiety and panic attacks, paranoid delusions, disorientation, depression, and suicidal ideation. Observers report irritability, aggression, violent behavior, tremors, and seizures. Medical evidence of adverse effects includes cardiovascular dysfunction and cardiac arrest, hypertension, hyperthermia, nausea and vomiting, and anorexia. There is no specific antagonist for synthetic cathinone intoxication. Patients with severe hyperthermia, seizures, and arrhythmia are medical emergencies and should be treated in a hospital. Sedation with benzodiazepines can be useful for managing agitation, seizures, aggression, and other related symptoms. Antipsychotic medications may be necessary for management of severe and persistent psychiatric symptoms.

Discovery of the psychedelic effects of LSD led to an epidemic of LSD abuse during the 1960s. Imposition of stringent constraints on the manufacture and distribution of LSD (classified as a Schedule I substance by the U.S. Food and Drug Administration [FDA]) and public recognition that psychedelic experiences induced by LSD were a health hazard have resulted in a reduction in LSD abuse. LSD still remains popular among adolescents and young adults, and there are indications that LSD use among young persons has been increasing in some areas in the United States. In 2011, an estimated 358,000 persons used LSD, whereas 200,000 and 271,000 persons reported LSD use in 2003 and 2007, respectively.

LSD is a very potent hallucinogen; oral doses as low as 20 μg may induce profound psychological and physiologic effects. Tachycardia, hypertension, pupillary dilation, tremor, and hyperpyrexia occur within minutes following oral administration of 0.5–2 μg/kg. A variety of bizarre and often conflicting perceptual and mood changes, including visual illusions, synesthesias, and extreme lability of mood, usually occur within 30 min after LSD intake. These effects of LSD may persist for 12–18 h, even though the half-life of the drug is only 3 h.

Emergency ward visits involving LSD totaled nearly 5000 in 2011. The most frequent acute medical emergency associated with LSD use is a panic episode (the “bad trip”), which may persist up to 24 h. Management of this problem is best accomplished by supportive reassurance (“talking down”) and, if necessary, administration of small doses of anxiolytic drugs. Adverse consequences of chronic LSD use include an enhanced risk for schizophreniform psychosis and derangements in memory function, problem solving, and abstract thinking. Treatment of these disorders is best carried out in specialized psychiatric facilities.

Tolerance develops rapidly for LSD-induced changes in psychological function when the drug is used one or more times per day for >4 days. Abrupt abstinence following continued use does not produce withdrawal signs or symptoms. There have been no clinical reports of death caused by the direct effects of LSD.

PCP, a cyclohexylamine derivative, is widely used in veterinary medicine to briefly immobilize large animals and is sometimes described as a dissociative anesthetic. PCP binds to ionotropic N-methyl-d-aspartate (NMDA) receptors in the nervous system, blocking ion current through these channels. PCP is easily synthesized and is abused primarily by young people and polydrug users. It is used orally, by smoking, by snorting, or by IV injection. It is also used as an adulterant in THC, LSD, amphetamine, or cocaine. The most common street preparation, angel dust, is a white granular powder that contains 50–100% of the drug. Low doses (5 mg) produce agitation, excitement, impaired motor coordination, dysarthria, and analgesia. Physical signs of intoxication may include horizontal or vertical nystagmus, flushing, diaphoresis, and hyperacusis. Behavioral changes include distortions of body image, disorganization of thinking, and feelings of estrangement. Higher doses of PCP (5–10 mg) may produce profuse salivation, vomiting, myoclonus, fever, stupor, or coma. PCP doses of ≥10 mg cause convulsions, opisthotonus, and decerebrate posturing that may be followed by prolonged coma.

In 2011, more than 75,000 emergency ward admissions involved PCP. The diagnosis of PCP overdose is difficult because the patient’s initial symptoms (anxiety, paranoia, delusions, and hallucinations) may suggest an acute schizophrenic reaction. Confirmation of PCP use is possible by determination of PCP levels in serum or urine. PCP assays are available at most toxicologic centers. PCP remains in urine for 1–5 days following high-dose intake.

PCP overdose requires emergency life-support measures that may involve treatment of coma, convulsions, and respiratory depression in an intensive care unit. There is no specific antidote or antagonist for PCP. PCP excretion from the body can be enhanced by gastric lavage and acidification of urine. Death from PCP overdose may occur as a consequence of some combination of pharyngeal hypersecretion, hyperthermia, respiratory depression, severe hypertension, seizures, hypertensive encephalopathy, and intracerebral hemorrhage.

Acute psychosis associated with PCP use is a psychiatric emergency because patients may be at high risk for suicide or extreme violence toward others. Phenothiazines should not be used for treatment because these drugs potentiate PCP’s anticholinergic effects. Haloperidol (5 mg IM) has been administered on an hourly basis to induce suppression of psychotic behavior. PCP, like LSD and mescaline, produces vasospasm of cerebral arteries at relatively low doses. Chronic PCP use has been shown to induce insomnia, anorexia, severe changes in behavior, and, in some cases, chronic schizophrenia.

This naturally occurring herb is a recent entry into the spectrum of hallucinogens. Like PCP and ecstasy, this drug can produce profound alterations in mood, hallucinations, and distorted perceptions. This drug is available on the Internet and is known by a variety of names including magic mint, mystic sage, Mariana Pastora, and purple sticky. The drug was first added to the annual National Surveys on Drug Use and Health in 2006, and its use is increasing. Between 2006 and 2011, the number of estimated users in the United States nearly tripled to more than 5000.

The active ingredient is salvinorin A, a selective kappa opioid receptor agonist that has a range of effects including hallucinations, sedation, analgesia, and depression. The hallucinatory symptoms may be associated with intense anxiety and severe agitation that can be managed with benzodiazepines. Importantly, this kappa opioid receptor agonist does not produce respiratory depression, and no significant change in blood pressure or heart rate was reported in a clinical study with healthy subjects.

Salvinorin A extract or crushed leaves of the Salvia divinorum plant can be chewed and absorbed through the buccal membrane or inhaled during smoking. The onset of the acute “high” is within 5–10 min after chewing and 30 s after inhalation. The duration of the effect is relatively brief, usually 15–20 min. However, if the drug is taken with alcohol or other hallucinogens, the duration and intensity of adverse effects may be increased. The effects of the drug are reported to be similar to those of ketamine, LSD, and marijuana.

A number of other pharmacologically diverse drugs of abuse are often referred to as “club drugs” because these are frequently used in bars, at concerts, and at rave parties. Commonly abused club drugs include flunitrazepam, GHB, and ketamine and are described below. Methamphetamine, MDMA, and LSD are also considered club drugs and were described earlier in this chapter. Abuse of club drugs at high doses, especially in combination with alcohol, can be lethal and should be treated as a medical emergency. GHB and ketamine can be identified in blood, and flunitrazepam can be identified in urine and hair samples. Flunitrazepam and GHB toxicity can be treated with antagonists at benzodiazepine and γ-aminobutyric acid B (GABA_B) receptors, respectively.

Flunitrazepam (Rohypnol) is a benzodiazepine derivative primarily used to treat insomnia, but it has significant abuse potential because of its strong hypnotic, anxiolytic, and amnesia-producing effects. It is a club drug commonly referred to as a “date-rape drug” or “roofies.” The drug enhances GABA_A receptor activity, and overdose can be treated with flumazenil, a benzodiazepine receptor antagonist. Flunitrazepam is typically used orally but can be snorted or injected. Concomitant use of alcohol or opioids is common, and this enhances the sedative and hypnotic effects of flunitrazepam and also the risk of motor vehicle accidents. Overdose can produce life-threatening respiratory depression and coma. Abrupt cessation after chronic use may result in a benzodiazepine withdrawal syndrome consisting of anxiety, insomnia, disordered thinking, and seizures.

GHB (Xyrem) is a sedative drug that is approved by the FDA for the treatment of narcolepsy. It is classified as a club drug, is sometimes used in combination with alcohol or other drugs of abuse, and has been implicated in cases of date rape. It is also used by body builders as a growth hormone stimulant. GHB is usually available as a liquid, is taken orally, and has no distinctive color or odor. Its stimulant properties are attributed to agonist activity at the GHB receptor, but it also has sedative effects at high doses that reflect its activity at GABA_B receptors. GABA_B antagonists can reverse GHB’s sedative effects, and opioid antagonists (naloxone, naltrexone) can attenuate GHB effects on dopamine release. Low doses of GHB may produce euphoria and disinhibition, whereas high doses result in nausea, agitation, convulsions, and sedation that can lead to unconsciousness and death from respiratory depression. In 2011, more than 2400 emergency ward admissions involved GHB.

Ketamine (Ketaset, Ketalar) is a dissociative anesthetic, similar to PCP. In veterinary medicine, it is used for brief immobilization. In clinical medicine, it is used for sedation, analgesia, and to supplement anesthesia. Ketamine increases heart rate and blood pressure, with less respiratory depression than other anesthetics. Ketamine’s popularity as a club drug appears to reflect its ability to induce a dissociative state and feelings of depersonalization, accompanied by intense hallucinations and subsequent amnesia. It can be administered orally, by smoking (usually in combination with tobacco and/or marijuana), or by IV or IM injection. Like PCP, it binds to NMDA receptors and acts as a noncompetitive NMDA antagonist. In 2011, ketamine accounted for 1550 emergency ward admissions. Ketamine has a complex profile of action and appears to be useful as an antidepressant in treatment-resistant patients and as an analgesic in patients with chronic pain. The extent to which chronic recreational use leads to memory impairment remains controversial.

Although some drug abusers may prefer a particular drug, the concurrent use of multiple drugs is common. Polydrug abuse often involves substances that may have different pharmacologic effects from the preferred drug. For example, concurrent use of such dissimilar compounds as stimulants and opioids or stimulants and alcohol is common. The diversity of reported drug use combinations suggests that achieving a change in subjective state, rather than any particular direction of change (stimulation or sedation), may be the primary reinforcer in polydrug abuse. There is also evidence that intoxication with alcohol, opiates, and cocaine is associated with increased tobacco smoking. Nicotine and cocaine enhance each other’s effects in clinical laboratory studies, and this drug combination maintains significantly higher levels of self-administration than either drug alone in preclinical models of addiction. There are relatively few controlled studies of multiple drug interactions. However, the combined use of cocaine, heroin, and alcohol increases the risk for toxic effects and adverse medical consequences. Similarly, some hallucinogens (MDMA, LSD) and club drugs (GHB, ketamine, flunitrazepam) are used in various combinations with an associated increase in toxic consequences.

One determinant of polydrug use patterns is the relative availability and cost of the drugs. For example, alcohol abuse, with its attendant medical complications, is one of the most serious problems encountered in former heroin addicts participating in methadone maintenance programs. Cocaine abuse often increases during methadone maintenance.

The physician must recognize that perpetuation of polydrug abuse and drug dependence is not necessarily a symptom of an underlying emotional disorder. Neither alleviation of anxiety nor reduction of depression accounts for initiation and perpetuation of polydrug abuse. Severe depression and anxiety are the consequences of polydrug abuse as frequently as they are the antecedents. Interestingly, some adverse consequences of drug use may be reinforcing and contribute to the continuation of polydrug abuse.

Adequate treatment of polydrug abuse, as well as other forms of drug abuse, requires innovative intervention programs. The first step in successful treatment is detoxification, a process that may be difficult when several drugs with different pharmacologic actions (e.g., alcohol, opiates, and cocaine) have been abused. Because patients may not recall or may deny simultaneous multiple drug use, diagnostic evaluation should always include urinalysis for qualitative detection of psychoactive substances and their metabolites. Treatment of polydrug abuse often requires hospitalization or inpatient residential care during detoxification and the initial phase of drug abstinence. When possible, specialized facilities for the care and treatment of drug-dependent persons should be used. Outpatient detoxification of polydrug abuse patients is unlikely to be effective and may increase risk for dangerous medical consequences.

Drug abuse disorders often respond to effective treatment, but periods of relapse may occur unpredictably. The physician should continue to assist patients during episodes of relapse with compassion and understanding. The physician and the patient must recognize that occasional recurrent drug use is not unusual in this complex behavioral disorder.