X, liquid E, and special K - the abuse of drugs at clubs and raves

American Journal of Pharmaceutical Education, Summer 2002 by Romanelli, Frank, Smith, Kelly M

PROLOGUE

Clinical toxicology is a topic instructed at some level in most colleges of pharmacy. Traditionally, instruction involves an array of commonly encountered toxic ingestions that might include: acetaminophen, tricyclic antidepressants, and benzodiazepines. Recently, an emerging group of chemicals known as "club drugs" have become increasingly popular substances of abuse. Commonly cited in the lay press, club drugs have become especially popular across college campuses in the United States(1).

Methylenedioxymethamphetamine (e.g., MDMA, ecstasy) has been reported to be the fastest growing abused drug in the US(1). In 2000, 1.3 million high school seniors consumed MDMA, while approximately 450,000 admitted to being current users(2). The Community Epidemiology Working Group (CEWG) reported the spread of MDMA use to 17 of 21 metropolitan areas assessed, with use expanding to a variety of settings including house parties(3). Of patients aged 14 to 24 enrolled in a recovery program in Seattle, 44 percent had used ecstasy, while 43 percent of those older than 25 years had also done so. Based on trends identified by CEWG, the National Institute on Drug Abuse (NIDA) launched a multimedia campaign to address emerging club drug use trends in 2000.

To assess club drug knowledge, we conducted a survey of baseline club drug knowledge amongst third year professional students at the University of Kentucky College of Pharmacy2. Seventy-two of seventy-eight students completed the survey for a response rate of 92 percent. When asked to describe a club drug, only six percent of students were able to correctly identify these substances as agents used to enhance social interactions and reduce inhibitions within party and club settings. Only 50 percent of respondents could correctly identify the most common age group and socioeconomic status of club drug users. When questioned specifically about individual agents, 53 percent of respondents correctly identified at least two clinical effects of MDMA, 57 percent of respondents correctly identified two clinical effects of gammahydroxybutyrate (GHB), and 14 percent of respondents correctly identified two clinical effects of ketamine. In general even fewer students could accurately describe management strategies for club drug ingestions. Six percent of students could correctly identify one management strategy for MDMA ingestion, 68 percent for GHB ingestion, and 10 percent for ketamine.

In response to statistics reflecting the increasing abuse of club drugs and considering the low level of knowledge amongst both pharmacy students and pharmacists regarding the clinical effects and management strategies for club drug ingestions, a "Club Drug Module" was designed for instruction to third year professional students. Information provided to students included drug sources, clinical presentation, pharmacology, and therapeutic management strategies. The module also incorporates a presentation regarding preventative efforts provided by a state law enforcement official.

METHYLENEDIOXYMETHAMPHETAMINE (MDMA)

MDMA was initially developed in 1914 as an appetite suppressant(4). The drug product was never marketed but did demonstrate some efficacy in the 1970s as a means to enhance communication in behavioral therapy sessions(5). In the 1980s, MDMA became popular among young adults attending raves and all nightclubs. More commonly known as X or ecstasy, MDMA is classified as a schedule I controlled substance(6). In 2001, the FDA approved a clinical trial examining MDMAs effects on post-traumatic stress disorder. This will be the first FDA approved clinical trial involving MDMA since the drug was made illegal(7).

MDMA is commonly manufactured in clandestine laboratories throughout Europe and the U.S. A great deal of the product is imported from Amsterdam, which is considered by many to be the "Ecstasy Capital of the World." Beyond ecstasy, various street names for MDMA exist including: X, ADAM, XTC, and Hug drug(6). Tablets, which typically contain from 50-150 mg. of active drug, are usually imprinted with a popular icon such as the Nike swoosh or Motorola symbol. Users sometime refer to MDMA by these imprints (e.g., "a smurf pill"). MDMA is typically purchased in the setting where it will be abused, most commonly raves. Raves are party venues characterized by the presence of loud music, marathon dancing, and laser light shows. Raves are often held in abandoned warehouses or factory buildings. Prices of MDMA range from $2040 per tablet and it is not uncommon for tablets to be adulterated with other chemicals, including aspirin, dextromethorphan, pseudoephedrine, and other drugs of abuse such as lysergic acid, heroin, and phencyclidine(8).

MDMA is structurally similar to the stimulant methamphetamine and to the hallucinogen mescaline, lending to its effects as both a stimulant and hallucinogenic(8). MDMA will affects neurotransmitters, including serotonin, dopamine, and norepinephrine(9). Release of these neurotransmitters by presynaptic neurons is often increased and their metabolism by monoamine oxidases inhibited, resulting in excessive synaptic concentrations(9).