Healthcare professionals across the country are seeing a new and alarming trend in drug abuse. As doctors and parents, it is important that we are aware of these substances and understand how patients who use them may present.
1) Dextromethorphan (“Robotripping”): Street names are DXM, CCC, High C and skittles. These are most commonly seen in boys between 10-14 years of age. Dextromethorphan is commonly found in cough syrups such as Robitussin and is ingested at about 25 times the therapeutic dose. It causes a dissociative anesthesia similar to PCP. They are often other ingredients in these common cold medications such as Tylenol and chlorpheniramine that can cause harmful effects on the body including permanent liver damage. The effects of the dextromethorphan can include decreased alertness and transient hallucinations and risk for trauma due to the dissociative effects.
2) Bath Salts (MDPV): These are not actual bath salts, but designer hallucinogenic amphetamines or a newer version of “ecstasy” (MDMA). Common names on the market now include “M-shine” and “hooka cleaner.” The core substance is cathinone (from the khat plant). Patients often present with increased reflexes, teeth grinding (bruxism) and involuntary muscle contractions (clonus). They can have an increased heart rate and may have seizures and can exhibit psychotic behavior or paranoia (that may last for days). Other worrisome problems associated with bath salt use include running a very high fever, forming abnormal blood clots in the legs or lungs, and liver failure.
3) Jimson weed (Thorn Apple): Commonly found growing in back yards, each plant contains seed pods with numerous seeds. Each seed contains a varying amount of the drugs atropine, scopolamine and hyoscyamine. Eating seeds from one plant may produce a “mild trip” while ingesting seeds from another plant may contain 10-50x the amount of these drugs and produce skin redness, dilated pupils, delirium, urinary retention, decreased gastrointestinal motility and rapid heart rate.
4) Psilocybin mushrooms: The spores of the parent plant are harvested and are often distributed by gluing the spores to paper and then sold as “art.” When ingested, the seed spores may cause hallucinogenic effects. These are typically sold with a 10-mm syringe and a broth solution.
5) New marijuana drugs (THC homologues): Street names include “spice” and “K2”. Often sold in combination with herbs for smoking. These are unregulated herbal substances which are often mixed with alcohol or acetone and sprayed on a plant which is then dried and sold. A single joint contains much higher doses of THC (300mg) than traditional THC. Clinical effects may include red eyes, rapid heart rate, dry mouth, and perceptual changes. Agitation, hallucinations and displaying behavior that may lead to trauma. Synthetic marijuana can also cause seizures, or acute psychotic episodes that can lead to suicidal thoughts. Other problems such as chest pain, psychological dissociation and panic attacks may occur. Sometimes the synthetic marijuana that has been sprayed on plants is also combined with formaldehyde (solvent containing PCP) that causes the user to present as acutely psychotic and violent. Most urine drug screens unfortunately do not detect these substances.
6) “Pharming, bowling or fruit parties”: This is a practice where teenagers get together and bring samples of medication that they get from their home (most commonly from their parents’ medicine cabinet). All samples are placed in a bowl and pills are ingested randomly. Overdoses on medications for diabetes, high blood pressure and heart problems are common in addition to possible respiratory depression and even death from narcotics, or benzodiazepines or the mixture of multiple substances.
7) Soma Coma: Also called “Trinity” if mixed with other drugs. Soma (carisoprodol) is a non-scheduled drug that is marketed as a muscle relaxer. It is very similar to a benzodiazepine such as Valium and heavily abused. It is a heroin substitute when combined with other drugs and its effects are very unpredictable and may predispose the individual to injuries from falls or other trauma. Many of these users have a history of heroin abuse.
8) Salvia divinorum: This is a mint plant common in Mexico. It is dried and concentrated before being sold, often in online tobacco shops. The salvinorin A contained in the plant is a psychoactive chemical. It is usually ingested by smoking in a water bong. Produces a trance-like high for 5-10 minutes.
9) Alprazolam: Abuse is on the rise as this medication is commonly used as a “downer” after cocaine use. Because of its characteristic shape, street names including “candy bars,” “coffins,” or “french fries” may be used. Pills are swallowed, crushed and snorted.
10) Cocaine: Because of the expense, not much cocaine sold on the street is pure. In fact up to 30-40% of some samples contain a common medication used to treat worms in veterinary animals. Highest use among those 18-25 years of age. Patients who use cocaine may present to a hospital or clinic having a high fever and have low blood cells or platelets, and have red spots on their nose or ears. Cocaine also increases the stickiness of platelets and therefore increases risk of heart attack or stroke. Look for blisters on the thumb and index finger of the dominant hand and scabs or burns around the lips.
11) Methamphetamines: After marijuana, it is the most widely abused drug worldwide. Approximately 5% of the US population has used methamphetamine, with an estimated 500,000 people using the drug in a given month. It may be synthesized via simple reactions using readily available chemicals and over-the-counter cold medicines, such as Sudafed. May be ingested orally, rectally, vaginally, be injected, inhaled, or sniffed. The effects are stronger and last longer than cocaine. In fact, the prolonged duration of action of methamphetamine (approximately 20 hours) helps differentiate it from cocaine (duration of action 30 minutes) and PCP (duration of action less than 8 hours). It causes rapid physical deterioration, weight loss, and poor dentition (“meth mouth”). Life-threatening intoxication is characterized by high blood pressure with rapid heart rate and severely agitated delirium, fever, metabolic acidosis and seizures. Medical providers should consider diagnosis of methamphetamine intoxication in any sweaty patient with high blood pressure, rapid heart rate, severe agitation and psychosis. Acutely intoxicated patients may become extremely agitated and pose a danger to themselves, other patients, and medical staff. Symptoms of methamphetamine withdrawal may develop within hours and typically peak within 1-2 days, and most often decrease within 2 weeks. During the acute withdrawal period (“the crash”), signs and symptoms may include restlessness, the inability to experience pleasure, fatigue, increased sleep, vivid dreams, insomnia, agitation, anxiety, drug craving and increased appetite. The prolonged withdrawal phase can last for up to 3 weeks and can include insomnia or even increased sleep, appetite changes, depression and possible suicidal thoughts.
12) Inhalants (poppers, snappers, rush): The use of these substances usually decreases as the individual grows older. Can cause a rapid high, drowsiness, lightheadedness, agitation as well as belligerence, impaired judgment, balance problems, and addiction. These inhalants may include halogenated hydrocarbons (butane), VCR head cleaner, whipped cream (contains nitrous oxide), colored spray paint (gold color is most popular), amyl and butyl nitrates (poppers, snappers, rush). “Sudden sniffing death syndrome” is a worrisome problem.
13) Opiates: These are also commonly called narcotics (heroin, Demerol, morphine, codeine, fentanyl, oxycodone, hydrocodone, and methadone). Patients who overdose are often sleepy and have a decreased respiratory rate, decreased gastrointestinal motility, urinary retention and pinpoint pupils. As a medical provider it’s important to strip an overdosed patient and look for fentanyl patches on the body, but be careful of possible uncapped needles or syringes in the pockets.
There are an increasing number of patients being diagnosed with hepatitis C linked to heroin and other opioid use and that rate is expected to continue increasing.
Street Price: Vicodin (hydrocodone/Tylenol) is a prescription medication with a street value of $5/pill depending on the geographic location where it’s purchased. Percocet (oxycodone/Tylenol) or OxyContin sells for about 50 cents to $1/mg but again this varies depending on geographic location and how much is purchased. Buprenorphine/naloxone (Suboxone) which is often prescribed to patients who have a narcotic addiction sells for $5-$20/pill on the street.
Patients presenting to the medical clinic may present in the state of overdose, drug-seeking or withdrawal. Treatment of overdose may include the use of naloxone. Narcotic withdrawal symptoms may occur on the first or second day of being without the drug. Patients may present with goose bumps (where the saying “quitting cold turkey” came from), patients on the third day may be on the floor flapping about with muscle cramps or kicks (i.e. “kicking the habit”). Other symptoms include anxiety, insomnia, yawning, tearing, sweating, runny nose, all over muscle aches, nausea, vomiting, diarrhea, hot and cold flushes, muscle twitches, abdominal cramps. Onset of symptoms usually occur within 8 hours of last use with a peak in 2-3 days. Treatment of withdrawal symptoms may include clonidine, ibuprofen, Benadryl, Phenergan, or Imodium.
It is important for medical providers, parents, law enforcement and teachers to be educated about drugs of abuse that our patients are using and be able to recognize the symptoms of intoxication, drug-seeking or withdrawal and treat our patients appropriately. The first step in helping protect our patients is learning about some of the drugs of abuse, and signs and symptoms of abuse.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO
Clinical experience with and analytical confirmation of “bath salts” and “legal highs” (synthetic cathinones) in the United States, Clin Toxicol (Phila), 2011 Jul; 49(6):499-505
Severe toxicity following synthetic cannabinoid ingestion. Clin Toxicol (Phila), 2011 Oct;49(8):760-4
White, Suzanne R (2011, November) Current Trends in Drug Abuse, Lecture Detroit Trauma Symposium, Detroit, MI.
Kloss, Brian T (2011, June) Drugs of Abuse Seen in the ED, Lecture – Impact 2011 AAPA Annual Conference