THE CLUB OF TORTURED SOULS

Recently, one of my patients with bipolar disorder took Ecstasy at a rave.
Within 60 minutes she had collapsed on the dance floor from dehydration.

After a thorough assessment in the emergency room, she was given
intravenous fluid replacement and sent home. The following day she came to
my office for a follow-up visit, experiencing a precipitous decline in her
mood.

This two-part series will look at four commonly used club drugs: Ecstasy
(3,4-methylenedioxymethamphetamine or MDMA), GHB (gamma-hydroxybutyrate),
Rohypnol or the date-rape drug (flunitrazepam), and ketamine. How do these
drugs work and what are the health risks?

The club drugs stimulate the release of the neurotransmitters serotonin,
norepinephrine and dopamine from brain cells. These neurotransmitters are
intimately involved with mood stability. People use club drugs to enhance
social interaction: They feel less inhibited and experience increased
empathy, physical closeness and euphoria.

MDMA is the drug of choice at a majority of raves. It is an amphetamine
derivative originally developed in 1914 for use as an appetite suppressant,
but it never got past animal testing. Its chemical structure is similar to
the hallucinogen mescaline. MDMA is addictive but less so than amphetamine,
and it does not cause psychosis as often as LSD or other hallucinogens.

Many of the illicitly manufactured MDMA tablets are not pharmaceutical
grade. They can contain "binders" or extra ingredients such as caffeine,
dextromethorphan (cough suppressant), pseudoephedrine (decongestant), or
hallucinogens like LSD or other potent amphetamine derivatives. The latter
two ingredients in combination with MDMA can have strong unpleasant
hallucinogenic effects.

MDMA's effects occur 30 to 60 minutes after ingestion, faster if it is
crushed or if its powder form is snorted. The effects can last up to eight
hours. Serotonin, dopamine and norepinephrine flood the synapses or spaces
between the nerve cells. This effect is enhanced by MDMA's ability to block
a brain enzyme that breaks down these neurotransmitters.

The euphoria occurs after a brief feeling of agitation, time
disorientation, lack of appetite and reduced thirst. Some people may
experience a mildly locked jaw (trismus) or will grind their teeth
(bruxism). Both of these side effects can be tempered by sucking on a lollipop.

The overstimulation of the brain and central nervous system can lead to a
serious life-threatening condition. The heart rate and blood pressure can
increase above acceptable limits. Some users will experience tremors,
seizures, clinically significant irregular heart beat (arrythmias),
parkinsonism, esophoria (the eyes turn inward -- cross-eyed) and an
inability to urinate (urinary retention).

The most serious side effect of MDMA ingestion is an elevated core body
temperature (hyperthermia) due to serotonin syndrome. This syndrome can
lead to muscle rigidity and seizures, muscle breakdown (rhabdomyolysis),
acute kidney and liver failure, adult respiratory distress syndrome, and
blood clotting abnormalities.

MDMA also stimulates the pituitary gland in the brain to release
antidiuretic hormone (ADH). This hormone will reduce the kidneys' ability
to produce urine in response to an increased fluid load; they cannot
excrete water into the bladder.

This creates a 'perfect storm' of pathology. The body overheats from
dancing and the effects of the drug. The kidneys shut down. The user will
dramatically increase his or her intake of water and other fluids in
response to increased body temperature. Without the kidney's ability to
excrete water, the fluid overload reduces the blood sodium concentration
(hyponatremia) through dilution. Low sodium concentration levels coupled
with high body temperatures can cause confusion, delirium, paranoia,
headache, anorexia, depression, insomnia, irritability, and a rapid,
involuntary, oscillatory motion of the eyeball (nystagmus), all of which
may continue for several weeks.

Several days after using ecstasy, the effects of serotonin depletion can
cause depression, and for some it is severe. People who repeatedly use MDMA
increase their risk of cognitive deficits and potentially permanent memory
impairment.

MDMA does change the brain's normal function. Indeed, studies indicate that
long-term use in typical recreational doses can lead to a paranoid
psychosis that cannot in practice be distinguished from schizophrenia.
Prolonged drug abstention will lead to a reversal of the psychosis.

There are some animal and human studies that indicate that MDMA use
(possibly in conjunction with cannabis) can lead to cognitive decline in
otherwise healthy young people.

My patient with bipolar disorder experienced a precipitous decline in mood
because the MDMA depleted the serotonin stores in her brain. People with
mental illness are more vulnerable to the deleterious effects of MDMA and
other club drugs. It is akin to a patient with asthma or chronic lung
disease who smokes. They will tend to have more severe disease and attacks
than someone who does not smoke.

These drugs are adulterated with other chemical additives and, although
most club drugs look like prescription medicines, they are illegally made
and can cause harm even in small doses.

I will return to the club in my next column to review GHB, Rohypnol and
ketamine.