CATR: This is a great topic because it’s been in the news lately and it is one that a lot of people don’t know much about. We’ve heard about designer drugs; we’ve heard about club drugs. I’m not sure if most of us really know if there’s any difference between the two or how they are defined.
Dr. Weaver: Designer drugs are derivatives of other drugs, some of which occur naturally. Designer drugs in a specific category can be referred to by brand names or by individual or street ones. One category of designer drugs are synthetic cannabinoids, which are laboratory-produced versions of the THC (tetrahydrocannabinol) found in marijuana. Some brand names of synthetic cannabinoids that you may have heard of are K2 and Spice. Then there are the bath salts, which are similar to ecstasy and gaining in popularity. Bath salts is kind of a catch-all name for the various cathinone and cathinone-derivative products. Cathinones originate from the khat plant, which is grown in the Middle East and is often chewed there and used as a mild stimulant, similar to a cup of coffee. But bath salts are concentrated formulations and are much more potent. One of the newer stimulant/hallucinogens most similar chemically to bath salts is called Flakka. Around the Texas area it is also known as gravel. Some of its other street names are Vanilla Sky and Ivory Wave. Another group of designer drugs that have recently emerged are synthetic versions of other synthetic drugs. A fairly popular synthetic hallucinogen called 25i-NBOMe, known on the street as N-bomb or Smiles, is a derivative of LSD. Ecstasy (methylene dioxy-methamphetamine, or MDMA) which contains both stimulant and hallucinogen-type properties, is another type of designer drug. It often goes by the street name molly and can also be categorized as a club drug.
CATR: What are club drugs?
Dr. Weaver: The classification “club drugs” was coined by the National Institute on Drug Abuse (NIDA) to identify drugs commonly used on the club scene, or at dance parties, raves, and circuit parties. Although there is some overlap between designer drugs and club drugs, club drugs tend to be more established ones that include things like methamphetamine and ketamine. Club drugs also include the “date rape” drugs such as GHB and flunitrazepam. Unlike designer drugs, club drugs are not necessarily made up of new chemicals that are derivatives of something else. An exception to this is ecstasy, which is an example of both a club and designer drug.
CATR: In a typical psychiatric practice, are these drugs in fairly common use?
Dr. Weaver: They tend to be used by teenagers and young adults. Child psychiatrists will definitely be seeing these patients, but the age range goes up to 40 or so. Among young adults where I have the most information, synthetic cannabinoids are second only to actual marijuana in terms of popularity. Someone who is using marijuana regularly may use synthetic cannabinoids periodically. Younger users and newer users may opportunistically try some of these drugs if they are available, or they may seek them out because of their trendy names and colorful packaging. Designer drugs are marketed as “legal highs” since they may not yet monitored or enforced by any local or federal laws. Currently, there is no specific urine test for designer drugs. Patients with the most to lose from a positive drug test outcome may gravitate towards these drugs because they are harder to detect. This could be a teenager on an athletic team, a professional athlete, a person on parole or probation, or a member of the military.
CATR: In the context of an outpatient setting where we may be seeing patients that are using these drugs, should we be approaching them differently? Do we now have to go down a long checklist and say, “Have you taken this?” “Have you taken that?”
Dr. Weaver: I think, for a clinician, awareness is one of the most important things. Forewarned is forearmed. So it’s good to be aware that these drugs are out there, that they are widely used, and that a negative drug screen doesn’t mean that the person isn’t using. And the usual sorts of things in a psychiatric interview: asking open-ended questions. Lists aren’t a bad thing necessarily. Knowing what some of the names for these drugs may help you establish some street cred. If you can ask them about bath salts, Spice, Scooby Snacks, N-bomb, they are more willing to open up.
CATR: Certainly with younger patients they have a feeling of invulnerability. We often talk to them about how dangerous drugs are, and they sort of say, “Yeah, yeah. We’ve heard this before. You’re a doctor. You’re supposed to say this.” How can we get around that attitude?
Dr. Weaver: Well, one of the ways I talk to patients about this is “buyer beware.” You don’t always know what you’re getting. Someone may be willing to cheat you with a cheaper, more dangerous substitute, or you may not know exactly what it is that you’re getting. Letting them know that there is a very real risk even if they do have that kind of immortal, invincible mindset. At best they may get a very bad scare and at worst a life-changing event that could impair their ability to finish school or get a job—to say nothing of potential legal consequences down the road as the laws do catch up with these drugs.
CATR: Are these drugs truly medically dangerous?
Dr. Weaver: Yes, these kinds of newer substances can have severe medical consequences. There are cases of people who have used just once or twice and have had life-changing problems: strokes and cardiac arrhythmias. These effects aren’t necessarily common, but they also are not as uncommon as we would like. There is a young lady here in Texas, not too far from Houston, who spoke recently at a summit on synthetic marijuana. She had used just a couple of times when she was 17 or 18 and ended up having a pretty severe stroke and is now in a wheelchair. In fact, the synthetic cannabinoids, the synthetic hallucinogens, and the bath salts have all had deaths attributed to them.
CATR: We’ve talked about some of the dangerous physical side effects. I imagine that these kinds of compounds can produce some pretty significant psychiatric effects as well. What might we see in patients?
Dr. Weaver: Most common are agitation, paranoia, anxiety, and varying degrees of delirium and hallucinations. Patients could also be experiencing something fairly similar to a psychotic break with some of these drugs, especially with the more stimulant-based ones like the cathinone derivatives—the bath salts. They are like taking amphetamines, and they can be pretty potent. It can be challenging to distinguish these symptoms from manic episodes or psychotic breaks, especially because oftentimes they will not show up on a standard drug screen. You might need to look for other clues.