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.
CATR: Such as?
Dr. Weaver: One clue would be red, bloodshot eyes if someone is using synthetic cannabinoids. You typically don’t see that in an acute psychotic break. You might also get a history of recent use, or they may have a package on their person or a chemical smell on their breath from recent smoking. You could also look for injection marks, although a lot of these drugs are snorted or smoked. If someone has a history of drug use, but the clinical picture isn’t consistent with that particular drug, then you should suspect synthetic. Keep in mind that patients who are concerned about legal consequences may not be quite as forthcoming as those that are just scared.
CATR: Has it been established if these drugs are addictive? Can people become dependent on them?
Dr. Weaver: Yes. There have been several cases of dependence. You can see cross-tolerance with marijuana among the synthetic cannabinoids. People can develop withdrawal, or they can be used to ameliorate the symptoms of withdrawal. With the bath salts or stimulants, people can have cravings for those on a regular basis. The synthetic hallucinogens are a little bit different in that respect, but people have used them enough to meet the criteria for substance use disorder and obviously have consequences as a result.
CATR: What can we do to help patients who come to us saying they want to get off these drugs?
Dr. Weaver: The treatments for designer drugs are similar to those for other substances in the young adult population. Unfortunately, there is not a substitution therapy like there is methadone or buprenorphine for the opioids, nicotine replacement for tobacco, or other treatments such as naltrexone for alcohol. Cognitive behavioral therapy or other types of therapeutic groups, such as 12-step programs, can help patients make positive environmental changes in order to reduce access and use. These standard treatments can be successful, although young adults are a challenging population because of the developing mind and mindset, “Well, that stuff won’t happen to me.” Family involvement can be very important in order to have an adequate support system and accountability.
CATR: Cannabinoids are now legal recreationally in a couple of states and certainly “medicinally” legal in many states. Would it be more reasonable for patients that are hell-bent on using synthetic cannabinoids like K2 or Spice to use regulated sources of standard cannabis?
CATR: Maybe this isn’t so relevant clinically, but more from the systems’ perspective, what is it about synthetic drugs that makes them so hard to stay on top of in terms of law enforcement?
Dr. Weaver: The reason they were called designer drugs in the first place is because they were designed to evade authorities. You might be able to arrest someone on suspicion of these drugs, but you wouldn’t be able to prosecute someone successfully because the product in possession is not strictly illegal—it’s the specific compounds within the drugs that are illegal.
Young adults are a challenging population because of the developing mind and mindset, “Well, that stuff won’t happen to me.” One of the ways I talk to my patients about [designer drugs] is “buyer beware.” You don’t always know what you’re getting. 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.
~ Michael Weaver, MD, FASAM
CATR: You would think that, with the techniques we have now, we could quickly determine their chemical makeup and say, “Okay this is a problem, we need to make this illegal.” Why isn’t that happening?
Dr. Weaver: The folks who make these drugs have access to chemical laboratories and the Internet. They know when the net is starting to close on particular substances, and they will quickly jump ahead to a similar sort of designer compound that is just different enough to evade detection. Currently, we are several generations into the different types of synthetic cannabinoids and bath salts in terms of the evolution of the chemical compound families that the clandestine manufacturers are producing. A number of states have started putting specific wording into the legislation to identify specific chemical compounds. But then you run into problems with things like dronabinol, which is a purified form of TCH that is available by prescription, and so it has legal protection and FDA-approval. You don’t necessarily want—from a legal standpoint—to tie the hands of people who have appropriate use of these other compounds for medicinal use.
CATR: In addition to Internet sales, are there also sales from legal stores, such as liquor stores or corner stores?
Dr. Weaver: They are commonly sold at convenience stores and head shops.
CATR: So if I own a head shop and I’m selling something and then I find out that my state has made it illegal (that chemical compound), do I then call my distributor and say, “Okay, do you have something with an extra hydrogen atom on it,” so it’s now the next generation?
Dr. Weaver: Yes, the distributors are usually ahead of the curve on this. They’ve already got the next couple of compounds in the pipeline and start moving updated products with new packaging so that people will continue using similar products.
CATR: I guess the bottom line is that there is a whole world of new compounds out there that we need to educate ourselves about, and we need to have some knowledge as we talk to our patients about them so we can have that suspicion, ask them about specific compounds, and be able to talk to them about the dangerous side effects that they may be oblivious to.
Dr. Weaver: Absolutely, and the good news is that treatment can certainly be successful.
CATR: Thank you, Dr. Weaver.