Ecstasy: The drug of a Ecstasy: The drug of a new generation.new generation.

Ecstasy = MDMAEcstasy = MDMA

3,4 methylenedioxymethamphetamine3,4 methylenedioxymethamphetamine X, E, M, XTC, Rolls, Adam, Bean, Hug DrugX, E, M, XTC, Rolls, Adam, Bean, Hug Drug

MDMA HistoryMDMA History

1912 – first synthesized by Merck1912 – first synthesized by Merck 1914 – patented by Merck – 1914 – patented by Merck –

manufactured as an appetite manufactured as an appetite suppressant, never marketedsuppressant, never marketed

1950’s- studied by US Army as potential 1950’s- studied by US Army as potential agent in psychological warfareagent in psychological warfare

1970 – used in psychotherapy, 1970 – used in psychotherapy, “penicillin for the soul”“penicillin for the soul”

1977 – class A illegal drug in UK1977 – class A illegal drug in UK 1985 – Schedule I illegal1985 – Schedule I illegal drug in U.S.drug in U.S.

Areas of UsageAreas of Usage

Highest at raves, Highest at raves, dance clubs (as dance clubs (as high as 91% of high as 91% of clubbers in dance clubbers in dance scene in Scotland)scene in Scotland)

Dramatic increase Dramatic increase in college use, in college use, suburban teens, suburban teens, house partieshouse parties

Millroy, CM, JRSM February 1999

Physical CLUESPhysical CLUES

Glowsticks or Glowsticks or lightslights

LollipopsLollipops PacifiersPacifiers Vick’s Vapor Rub Vick’s Vapor Rub

and Nasal Inhalerand Nasal Inhaler Fuzzy MittensFuzzy Mittens

Most Predictive Factor of Drug Use = CLUB MUSIC!

Methods of Methods of AdministrationAdministration Mainly PO – stamped tablets, capsulesMainly PO – stamped tablets, capsules Intra-nasal – rapid absorption of crushed Intra-nasal – rapid absorption of crushed

tablets or opened capsulestablets or opened capsules Intra-rectal – faster absorption than POIntra-rectal – faster absorption than PO Recreational usage varies from ½ pill to Recreational usage varies from ½ pill to

as much 15 pills in a 6 hour spanas much 15 pills in a 6 hour span

MDMA Adulterants MDMA Adulterants

MDEAMDEA MBDBMBDB MDAMDA PMAPMA CaffeineCaffeine DextromorphanDextromorphan AspirinAspirin PiracetamPiracetam

MethamphetamineMethamphetamine PCPPCP KetamineKetamine HeroinHeroin QuinineQuinine LSDLSD MarijuanaMarijuana EphedrineEphedrine

MDMAMDMA

OnsetOnset 20-90 20-90 minmin

Rise Rise upup

5-20 5-20 minmin

PlateaPlateauu

2-3 2-3 hourshours

Come Come downdown

1-2 1-2 hourshours

After After EffectsEffects

3-24 3-24 hrshrs

Positive EffectsPositive Effects

Extreme Extreme euphoriaeuphoria

Increased energyIncreased energy Feelings of Feelings of

belonging and belonging and closenesscloseness

Heightened Heightened sensations sensations (touch, taste, (touch, taste, smell, hearing)smell, hearing)

Increased Increased opennessopenness

Feelings of love Feelings of love and empathyand empathy

Bright, intense Bright, intense visual perceptionsvisual perceptions

Musical Musical appreciationappreciation

Fear dissolutionFear dissolution ““Profound” thoughtProfound” thought

Other EffectsOther Effects

Appetite lossAppetite loss Vertical Vertical

nystagmus nystagmus (rolling)(rolling)

Moderate Moderate increases in HR increases in HR and BP and BP

Mild visual Mild visual hallucinationshallucinations

Mind racingMind racing

Changes in Changes in thermoregulationthermoregulation

Restlessness, Restlessness, nervousness, nervousness, shiveringshivering

Strong desire to Strong desire to take more drug take more drug during come during come downdown

MydriasisMydriasis

Negative Side EffectsNegative Side Effects

Mild to extreme Mild to extreme trisma and trisma and bruxismbruxism

Short-memory lossShort-memory loss ConfusionConfusion Vertigo, ataxiaVertigo, ataxia Muscle tensionMuscle tension Nausea & vomitingNausea & vomiting Concentration Concentration

difficultiesdifficulties

““Crash” come Crash” come downdown

Hangover lasting Hangover lasting days to weeksdays to weeks

Depression and Depression and fatigue for up to fatigue for up to a weeka week

Psychological Psychological addictionaddiction

Panic attacksPanic attacks

Major Toxic Major Toxic ComplicatioComplicationsns Hyperthermia/Heat StrokeHyperthermia/Heat Stroke DehydrationDehydration HyponatremiaHyponatremia SIADHSIADH Hepatitis/Liver FailureHepatitis/Liver Failure Rhabdomyolysis/Renal FailureRhabdomyolysis/Renal Failure Neurotoxic EffectsNeurotoxic Effects Acute Psychotic Break/Severe DepressionAcute Psychotic Break/Severe Depression

Death!Death!

Ecstasy Related Ecstasy Related FatalitiesFatalities87 cases reported in the literature 87 cases reported in the literature

caused by:caused by: Hyperpyrexia – 30 Hyperpyrexia – 30 Hepatic – 4 Hepatic – 4 Cardiovascular/Cerebrovascular – 8 Cardiovascular/Cerebrovascular – 8 Cerebral, including Hyponatremia – 9 Cerebral, including Hyponatremia – 9 Drug Related Accidents or Suicide – Drug Related Accidents or Suicide –

1414 Unknown – 22 Unknown – 22

Kalant, H; Canadian Medical Association Journal, October, 2001

Major Physical Toxicity Major Physical Toxicity - Hepatic- Hepatic Mild viral hepatitis – jaundice, enlarged Mild viral hepatitis – jaundice, enlarged

tender liver, elevated LFT’s/Coags – tender liver, elevated LFT’s/Coags – self limited, 2 wks-3 mo, related to self limited, 2 wks-3 mo, related to glutathione decrease and oxidative glutathione decrease and oxidative cell destructioncell destruction

Prolonged hepatitis – slow recovery Prolonged hepatitis – slow recovery with potential permanent fibrosiswith potential permanent fibrosis

Fulminant liver failure – fatal without Fulminant liver failure – fatal without liver transplant liver transplant

Kalant, H; Canadian Medical Association Journal, October, 2001

Major Physical Toxicity Major Physical Toxicity - Cardiovascular- Cardiovascular NE responsible: HTN and tachycardiaNE responsible: HTN and tachycardia Major intracranial hemorrhageMajor intracranial hemorrhage Petechial hemorrhages – brain and Petechial hemorrhages – brain and

other organsother organs Retinal hemorrhage at autopsyRetinal hemorrhage at autopsy Intravascular thrombosis and CVAIntravascular thrombosis and CVA Serious cardiac dysrhythmiasSerious cardiac dysrhythmias Pulmonary edema/heart failurePulmonary edema/heart failure

Major Physical Major Physical Toxicity- CerebralToxicity- Cerebral Hyponatremia- result of vigorous physical Hyponatremia- result of vigorous physical

activity, profuse sweating, large Na+ loss, activity, profuse sweating, large Na+ loss, excessive water consumption excessive water consumption

SIADH – less common mechanism of water SIADH – less common mechanism of water retention, but can complicate pictureretention, but can complicate picture

Cerebral edema w/hyponatremic seizures – Cerebral edema w/hyponatremic seizures – therapy includes BZD’s and cautious therapy includes BZD’s and cautious replacement of Na with hypertonic salinereplacement of Na with hypertonic saline

Brain stem and cerebellum compressionBrain stem and cerebellum compression

Hyperpyrexic Pattern Hyperpyrexic Pattern of Toxicityof Toxicity Most dangerous form of ecstasy Most dangerous form of ecstasy

induced toxicityinduced toxicity Results from a combo of drug action, Results from a combo of drug action,

intense physical activity, and hot intense physical activity, and hot environmentenvironment

Adulterants such as dextromorphan Adulterants such as dextromorphan can inhibit sweating leading to further can inhibit sweating leading to further heat retentionheat retention

Changes resemble those seen Changes resemble those seen in severe heatstroke in severe heatstroke

Features of Features of HyperpyrexiaHyperpyrexia

Rhabdomyolysis – heat Rhabdomyolysis – heat production and muscle production and muscle necrosisnecrosis

Myoglobinuria and renal failure Myoglobinuria and renal failure – secondary to rhabdomyolysis– secondary to rhabdomyolysis

Hepatic necrosisHepatic necrosis DICDIC

PMAPMA

ParamethoxyamphetamineParamethoxyamphetamine Pills contain 50mg of PMA, look like Pills contain 50mg of PMA, look like

MDMA tabletsMDMA tablets Longer duration to onset – toxic in Longer duration to onset – toxic in

doses of 60-80mgdoses of 60-80mg Rapid rise in BP and temp leading to Rapid rise in BP and temp leading to

convulsions, coma, and deathconvulsions, coma, and death Responsible for 10 deaths (3 in Responsible for 10 deaths (3 in

suburbs of Chicago)suburbs of Chicago)

Gamma Hydroxybutyrate Gamma Hydroxybutyrate

AcidAcid (GHB) (GHB) Liquid ecstacy Liquid ecstacy Liquid GLiquid G Gamma Oh Gamma Oh Grievous bodily harm Grievous bodily harm Scoop Scoop SamatomaxSamatomax Bioski Bioski Cow Growth HormoneCow Growth Hormone Georgia Home BoyGeorgia Home Boy

GHBGHB

Analogue of inhibitory neurotransmitter Analogue of inhibitory neurotransmitter gamma-aminobutyirc acid- CNS gamma-aminobutyirc acid- CNS depressantdepressant

Synthesized in 1960 and used in 1970’s Synthesized in 1960 and used in 1970’s for sleep disorders because it induces for sleep disorders because it induces REM sleepREM sleep

Used in Europe as anesthetic agent until Used in Europe as anesthetic agent until found that it caused seizuresfound that it caused seizures

1977, study claimed it stimulated effects 1977, study claimed it stimulated effects of Growth Hormoneof Growth Hormone

GHB GHB

Unapproved drug in US, but Unapproved drug in US, but legally obtainable under FDA legally obtainable under FDA investigational New Drug investigational New Drug exemption for treatment of exemption for treatment of narcolepsynarcolepsy

–20 states have controlled 20 states have controlled its use with penalties its use with penalties similar to marijuana similar to marijuana possessionpossession

Gamma Hydroxybutyrate Gamma Hydroxybutyrate

AcidAcid (GHB) (GHB)

Readily available in drug market and Readily available in drug market and inexpensive and relatively easy to make inexpensive and relatively easy to make – recipes are obtainable on the internetrecipes are obtainable on the internet

Obtainable as clear and odorless liquid, Obtainable as clear and odorless liquid, gel, or powder which have a salty tastegel, or powder which have a salty taste– however, taste is masked by ETOH however, taste is masked by ETOH

which increases its clinical effectswhich increases its clinical effects

GHBGHB

Used in date rape because: Used in date rape because:

–quick onset of effectquick onset of effect

– easily obtainableeasily obtainable

– small quantities are neededsmall quantities are needed

–causes hallucinations and causes hallucinations and amnesia making the patient an amnesia making the patient an unreliable witness unreliable witness

GHBGHB

GHB - ToxicityGHB - Toxicity

Acts as neurotransmitter affecting GHB and Acts as neurotransmitter affecting GHB and GABA- B receptors causing CNS depressionGABA- B receptors causing CNS depression– takes effects in 15-30 minutes causing takes effects in 15-30 minutes causing

drowsiness, dizziness, and disorientationdrowsiness, dizziness, and disorientation– duration of action up to 3 hoursduration of action up to 3 hours– half life of 20 min to 1 hourhalf life of 20 min to 1 hour– hallmark is marked agitation upon hallmark is marked agitation upon

stimulation despite apnea and hypoxiastimulation despite apnea and hypoxia

10mg/kg causes vomiting, 10mg/kg causes vomiting, rapid onset of coma and rapid onset of coma and amnesiaamnesia

20-30mg/kg cause rapid cycles 20-30mg/kg cause rapid cycles of REM and non-REM sleepof REM and non-REM sleep

50mg/kg can cause resp 50mg/kg can cause resp depression, bradycardia, clonic depression, bradycardia, clonic muscle contractions, and muscle contractions, and decreased cardiac outputdecreased cardiac output

GHB - Other formsGHB - Other forms

Gamma butyrolactone (GBL) - can be Gamma butyrolactone (GBL) - can be purchased from chemical supply purchased from chemical supply stores or catalogues and converted to stores or catalogues and converted to GHB with NaOHGHB with NaOH– GBL is rapidly converted to GHB by GBL is rapidly converted to GHB by

peripheral lactonases within peripheral lactonases within minutesminutes

1,4-Butanediol - can be purchased in 1,4-Butanediol - can be purchased in similar manner as GBLsimilar manner as GBL

–converted to gamma converted to gamma hydroxybutyaldehyde by alcohol hydroxybutyaldehyde by alcohol dehydrogenasedehydrogenase

–then, converted to GHB by then, converted to GHB by aldehyde dehydrogenasealdehyde dehydrogenase

KetamineKetamine

KetamineKetamine

AKA: Special K, Super Acid, Super CAKA: Special K, Super Acid, Super C used as an anesthetic in EM and used as an anesthetic in EM and

veterinary medicineveterinary medicine Ketamine is a controlled substance in 18 Ketamine is a controlled substance in 18

states as schedule III drugstates as schedule III drug Used in date rape because:Used in date rape because:

– rapid onsetrapid onset– dissociative hallucinogenic dissociative hallucinogenic

Ketamine - ToxicityKetamine - Toxicity

Chemically related to PCPChemically related to PCP takes effect 15-20 minutes, takes effect 15-20 minutes,

producing analgesiaproducing analgesia Higher doses produces dissociative Higher doses produces dissociative

hallucinations, delirium, resp hallucinations, delirium, resp depresion, Sz, arrythmias and depresion, Sz, arrythmias and cardiac arrestcardiac arrest

Effects last 20-45minEffects last 20-45min

Ketamine - TreatmentKetamine - Treatment

Mainly supportiveMainly supportive No antidoteNo antidote Pt should be placed in quiet room Pt should be placed in quiet room

with minimal stimulationwith minimal stimulation

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