The Agony of Ecstasy, Act 2 - NTI 2016 Session

In Act 1 we looked at an overview of the impact designer drugs may have on those who experiment with them. Now let’s get a little deeper into the ugly side of these pernicious pharmaceuticals. Specialties PICU Article


The Agony of Ecstasy, Act 2 - NTI 2016 Session

What Are We Looking At?

There are four classes of drugs typically implicated in the rave culture. Stimulants and dissociatives are the two most commonly used agents.

Amphetamines and Stimulants

Methamphetamine (beanies, blue devils, chalk, CR, crank, crystal, crystal meth, fast, granulated orange, ice, meth, Mexican crack, pink, rock, speckled birds, speed, tina, yellow powder)

3-4, methylene-dioxymethamphetamine (Adam, bean, blue kisses, clarity, club drug, disco biscuits, E, ecstasy, hug drug, love drug, lover's speed, Mercedes, Molly, New Yorkers, peace, roll, white dove, X, XTC)

Cocaine (blow, C, candy, coke, do a line, freeze, girl, happy dust, Mama coca, mojo, monster, nose, pimp, shot, smoking gun, snow, sugar, sweet stuff, white powder)

Crack cocaine (base, beat, blast, casper, chalk, devil drug, gravel, hardball, hell, kryptonite, love, moonrocks, rock, scrabble, stones, tornado)

ADHD drugs (Ritalin ©, Adderal ©, Dexedrine ©, Vyvance ©, Concerta ©: crackers, one and ones, pharming, poor man's heroin, R-ball, ritz and t's, set, skippy, speedball, t's and ritz, t's and r's, vitamin R, west coast)

Nicotine, Caffeine! Dissociatives and Anaesthetics

Ketamine (bump, cat killer, cat valium, fort dodge, green, honey oil, jet, K, ket, kit kat, psychedelic heroin, purple, special "K", special LA coke, super acid, super C, vitamin K)

Phencyclidine (Angel dust, belladonna, black whack, CJ, cliffhanger, crystal joint, Detroit pink, elephant tranquilizer, hog, magic, PCP, Peter Pan, sheets, soma, TAC, trank, white horizon, zoom): may be mixed with marijuana or tobacco then smoked, or with other drugs in the rave drug family, such as MDMA, ketamine, LSD, mescaline or methamphetamine

Lysergic acid diethylamide (A, Acid, black star, blotter, boomers, cubes, Elvis, golden dragon, L, LSD, microdot, paper acid, pink robots, superman, twenty-five, yellow sunshine, ying yang)

Mescaline (beans, buttons, cactus, cactus buttons, cactus head, chief, love trip, mesc, mescal, mezc, moon, peyote, topi)

Psylocibin (boomers, god's flesh, little smoke, magic mushroom, Mexican mushrooms, mushrooms, musk, sherm, shrooms, silly putty, simple simon)

Plant materials such as Datura stamonium (Hell's bells, Jimson weed, locoweed) and Salvia divinorum may also be ingested via smoking, chewing, vaping or drinking as tea. The hallucinogenic effect depends on method of ingestion as well as purity of the product used.

Users tend not to appear in ERs unless they engage in behaviour leading to accidental self-harm. The psychological effect of particularly vivid or frightening hallucinations may be severe.


Gamma-hydroxybutyric acid (caps, cherry meth, ever clear, easy lay, fantasy, G, GHB, G-riffic, gamma hydrate, Georgia Home Boy, Grievous Bodily Harm, liquid ecstasy, liquid X, soap, sodium oxybate)

Flunitrazepam (circles, forget-me pill, la rocha, lunch money drug, Mexican valium, pingus, R2, Reynolds, roche, Rohypnol, roofies, rope, ruffles and wolfies)

Alcohol, Synthetic Opioids

Fentanyl (Apache, China girl, China town, dance fever, friend, goodfellas, great bear, he-man, jackpot, king ivory, murder 8, poison, tango and cash, TNT)


1-(4-Nitrophenylethyl)piperidylidene-2-(4-chlorophenyl)sulfonamide (aka W-18) was originally developed as a potential analgesic by chemists at the University of Alberta in 1981. It was abandoned only to be resurrected by labs in China. 100 times as potent as fentanyl, it has been found in tablets sold as oxycodone; its lethality means even a microscopic dose could be fatal. It is not known if naloxone is effective to reverse the effects. 4 kg of it was seized in Edmonton in December 2015, and 1.3 kg were seized in Florida last August.

What's the Attraction? Enhancing the RAVE experience

Stimulants produce euphoria, heightened sensations, altered sense of time, increased stamina, hypersexuality & psychedelic hallucinations; they may also produce tachycardia, hyperthermia, dry mouth, blurred vision, bruxism and dehydration. Onset of action is 30-45 minutes for oral ingestion, and duration is approximately 3-6 hours. Because of the slow onset of action, subsequent doses may be taken, which then produce a dramatic collapse.

Dissociatives produce euphoria, analgesia, amnesia, hallucinations, derealisation & depersonalization; more noxious effects may include hypertension, nausea & vomiting - aspiration is highly possible - & psychotic emergence reactions. Onset of action depends on route; snorting or injecting produces rapid onset (seconds) while oral ingestion takes 2-5 minutes. Duration of the high is about an hour for ketamine; hallucinations may continue for several hours. Continued use may cause renal failure.

Depressantsmay produce euphoria, hypersexuality, tranquility & a sense of well-being; hypotension, sweating, nausea, hallucinations, amnesia, somnolence, loss of consciousness (reported by 69% of GHB users) & coma are less welcomed effects and are potentiated by alcohol. Onset is rapid, 10-20 minutes following oral ingestion; duration may be as long as several hours and is dose-dependent.

Synthetic opioids create relaxation, euphoria, analgesia & hallucinations; they also cause respiratory depression, nausea, vomiting, arrhythmia, seizure and coma. Onset of effect is seconds when injected or inhaled and 15-30 minutes when taken orally. Duration is relatively brief, 1-2 hours when ingested.

The Ugly Side of Ecstasy

Stimulant effect > dehydration, hypertension, cardiac and renal failure

High doses > malignant hyperthermia, rhabdomyolysis, low cardiac output syndrome +/- cardiac arrest, cerebrovascular accident, seizure

Chronic abuse > confusion, depression, sleep disturbances, drug craving, severe anxiety and paranoia, psychotic episodes, muscle tension, involuntary teeth clenching, nausea, blurred vision, nystagmus, faintness, liver damage, chills/fever or sweating, hypertension and tachycardia may occur even WEEKS AFTER LAST DOSE

Long-term neurological damage > serotonin receptor destruction > impaired regulation of aggression, mood, sexual activity, sleep patterns, sensitivity to pain

Comparing Ecstasy to Cannabis

Recreational Ecstasy users are unimpaired in simple tests of alertness when under the influence while marijuana users are somewhat impaired.

However, they perform much worse on more complex tests of attention, alertness, memory, learning and tasks reflecting general intelligence, whether they're high or not. Cannabis effects on frontal attentional networks are generally not as significant as those of MDMA's hippocampal and frontal cortex effects.

Neurotoxic effects on cognition and executive function persist more often in MDMA-only users compared to cannabis-only users. Given that MDMA is rarely used alone, impairment in memory and complex thought processes may be additive.

Signs and Symptoms of MDMA Abuse

Chronic paranoid psychosis, flashbacks, anxiety, panic, confusion, suicidal depression, insomnia

Gum-chewing (reduces the distressing effects of jaw muscle fasciculations), weight loss, exhaustion, jaundice, acute hepatotoxicity, hepatitis, irritability, chest pain, tachycardia, hyperkalemia, spontaneous intracranial hemorrhage, retinal hemorrhage, central serous chorioretinopathy, decreased libido, anorexia, amnestic syndrome, severe ataxia, urinary retention likely related to adrenergic effects

PET shows decreased glucose uptake in caudate & putamen, which is more severe in those users starting before age 18

Hyponatremia from SIADH and increased H2O intake > cerebral edema & death may be 2o serotonin uptake increase, as is priapism (painful but not fatal)

γ- Hydroxybutyric Acid (GHB)

First developed as a general anaesthetic but withdrawn due to unacceptable side effects. Xyrem (Sodium oxybate) approved in 2002 as tx for narcolepsy is a Schedule III drug requiring restricted access and intensive monitoring programs.

The Draw

Euphoria, increased libido, sense of tranquility

When mixed with ETOH it becomes a date-rape drug via amnesia and inability to resist

Anabolic effects attractive to body builders for increased muscle mass and decreased body fat

The Downside

Acts on both GABAB and specific GHB receptors > CNS depression, stimulant and psychomotor effects > 95% hepatic metabolism, t1/2 30-60 minutes with only ~5% renal excretion which makes verification of ingestion very difficult. Urine levels are virtually nil within 24 hours and serum levels in as few as five hours.

Sweating, LOC, confusion, headache, nausea, auditory and visual hallucination, exhaustion, clumsiness, amnesia > steep dose-response curve with onset noted within 15 minutes. May be implicated in the phenomenon of excited delirium.

Overdose effects: respiratory depression - apnea or Cheyne-Stokes, acute respiratory acidosis, hypothermia, bundle branch block, bradycardia +/- hypertension, orthostatic hypotension, nystagmus, ataxia, vertigo, tonic-clonic seizure, aggression, impaired judgment, nausea, vomiting, aspiration > especially when combined with ETOH or other sedative-hypnotics

Addiction - a Bit of a Puzzle

Historically low levels in 8-12 grade population = 2 % or less

Withdrawal symptoms are usually severe and require in-patient, medically-supervised treatment for 7-14 days. Amnesia may cause repeated re-addiction - they don't remember they've taken it, or that they've been through a horrible withdrawal so they may resume using soon after rehab.

Benzodiazepines should not be administered to any patient suspected of chronic use; they worsen withdrawal symptoms and increase risk of severe respiratory depression, coma and death. Treatment of intoxication in absence of confirmatory evidence is supportive. Naloxone and other reversal agents do not work. If polypharmacy is suspected, gastric lavage and activated charcoal may be in order.

Baclofen may have role in tx withdrawal but is not FDA-approved (2014)

If you're still reading along, here is the personal story I promised in the introduction.

About 10 years ago on a Saturday morning, I got an alarming phone call from my daughter, who was away at university, The conversation went something like this:

"Mom, I think somebody put something in my drink last night."

M: "Are you okay? Did anything happen?"

"I started feeling really weird after only a couple of sips and I was scared. So I left and went home. So I'm okay, but I still feel weird."

M: "Oh. Well. I'm really glad you went home." "But if you're still feeling weird, you should go to the ED and get checked out."

She went to the ED, they gave her some IV fluids and sent off blood and urine for drug screens. The serum came back "no illicit substances detected", but the urine tox screen was positive for GHB. She was SOOOO lucky! And I was so thankful that she was safe.

Talk to your kids!

We've now gotten some solid information about the effects, both desired and unanticipated, of these drugs. In Act 3 we'll look at a couple of case studies that will bring the pieces together.

Act 1: The Agony of Ecstasy in PICU and Other Tales... a Play in 3 Acts - NTI 2016 Session

Act 3: The Agony of Ecstasy - Act 3... Ringing the Curtain Down

Pediatric Critical Care Columnist

Certified Pediatric Critical Care Nurse and parent of multi-handicapped adult son, married to computer geek.

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Specializes in Hospice.

Great article! Very timely too - I work EMS part time and this tends to be the time of year when we see a surge in drug use (nice weather, school getting out and we as an influx of "lakers" from some big cities coming to vacation in our lake community).


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May I share this article? A tragic event in Manila took place last Sunday and left 5 people dead. All after/ while attending a concert. This article is very informative and being allowed to share it on my FB account would be very helpful. Here is a link to CNN News article. The Closeup 'Forever Summer' concert tragedy: What we know so far - CNN Philippines

Roy Hanson

211 Posts

Specializes in as above.

where there is a need, and always will be, there be people to buy...but why! Are we that anxious and buzz out from work...we need booze or drugs to give us a holiday. If you going to do these 'recreational' careful. YOUR supposed to be a nurse..use your common sense. OR seek another job. I used to treat a lot of drug users, usually work related cause. Get used to it.

Thats why Afghanistan is the top producer of Poppy plants (heroin, cocaine) in the world. And we thought it was a tribal You can make a good living selling drugs, cash only. B.C. (Canada) has the top mary jane crops. Remember there is a world outside the great USA.

Pediatric Critical Care Columnist

NotReady4PrimeTime, RN

11 Articles; 7,358 Posts

Specializes in NICU, PICU, PCVICU and peds oncology.

Yes, please do.

Kitiger, RN

1,828 Posts

Specializes in Private Duty Pediatrics.
Yes, please do.

May any/all of us share this?

Pediatric Critical Care Columnist

NotReady4PrimeTime, RN

11 Articles; 7,358 Posts

Specializes in NICU, PICU, PCVICU and peds oncology.
May any/all of us share this?

As long as you properly credit this to and to me you may share it.

Specializes in Pediatrics Telemetry CCU ICU.

Florida is especially known for getting the "latest" designer drugs. There is one that is especially dangerous now called Flakka and they are on the lines of Bath Salts. This drug literally makes you insane. The aggression and strength of persons under the influence of this is amazing. They are calling it the "zombie" drug because it makes the person act like and look like a zombie from The Walking Dead, except faster and more aggressive.

Roy Hanson

211 Posts

Specializes in as above.

no matter what the name..its a drug, that if used properly, lol, gives the desired effect..makes the person feel better, or takes them away from reality for a few hours. Drugs will ALWAYS be around.

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