Trends in Adolescent Drug Abuse

Emerg Med 40(5):8, 2008

By Jane M. Prosser, MD, and Lewis S. Nelson, MD

If “pharming” looks like an urban variant of an agricultural term to you, you may be due for an update on the recreational habits of teens. The authors describe the latest drug fads in the adolescent population and tell how these drugs are used and abused, what effects they have, and how overdoses are treated.

Adolescent drug abuse is a significant problem in the United States and throughout the world. The scope of the problem can only be estimated. The Monitoring the Future study funded by the National Institute on Drug Abuse found that the self-reported prevalence of drug abuse (all drugs combined) among 12th graders in 2005 was 48%. Although rates of illicit drug abuse in adolescents have been declining, rates of prescription drug abuse are on the rise.

The U.S. government spent $1.6 billion on drug abuse prevention in 2007. In spite of this, new drugs and novel methods of use continue to be quickly circulated using current technology. In one small study, 100% of adolescent drug users had modified their drug use based on information obtained from the Internet (see box below). Instant messaging, email, and cell phones are used to disseminate drug information. Because many drug abusers end up in the emergency department, clinicians need to be aware of current trends and new drugs of abuse.

Web Sites with Information on Drugs of Abuse The following sites promote drug use, often in the form of “harm reduction,” or “safe” drug use: • www.erowid.org — “Provides access to reliable, nonjudgmental information about psychoactive plants and chemicals and related issues.” • www.lycaeum.org — “Works to promote public education about all aspects of psychoactive drugs and drug use.” • www.dextroverse.org — Devoted to the use of recreational dextromethophan The government site below, hosted by the National Institute on Drug Abuse, includes the dangers of “club drugs” and teaching materials for health professionals: • www.clubdrugs.org

ABUSE OF PRESCRIPTION OPIOID ANALGESICS

Rates of prescription drug abuse have risen sharply in the United States. The incidence doubled from 7.8 million users in 1992 to 15 million users in 2003. Cannabis (marijuana) is the only illicit drug abused by more Americans than prescription drugs. The Drug Abuse Warning Network (DAWN) estimates that patients visiting U.S. emergency departments who mentioned using pharmaceuticals for nonmedical purposes increased by 21% between 2004 and 2005. The Partnership for a Drug-Free America found that one in five teens admitted using prescription drugs to get high, and the National Survey on Drug Use and Health (NSDUH) found that prescription drugs are the most commonly abused category of drugs among 12- and 13-year-olds.

Why are teens abusing prescription drugs more than illicit drugs? One reason may be the misconception that prescription drugs are safer than street drugs. One-third of teens surveyed by The Partnership for a Drug-Free America believed there was “nothing wrong” with using prescription medications without a prescription. Two in five teens surveyed said that prescription medications were safer than illicit drugs, and 30% of teens said these drugs were not addictive.

Opioids (specifically, opioid analgesics) are among the most commonly abused prescription drugs. Emergency department visits related to opioids increased 24% and visits related to methadone increased 29% between 2004 and 2005. According to data from the Monitoring the Future study, oxycodone (OxyContin) abuse increased by almost 40% between 2002 and 2005, to an annual prevalence of 5.5% among 12th grade students. Hydrocodone/acetaminophen (Vicodin) is also widely abused—7.4% of college students aged 18 to 22 reported abusing it in 2005.

According to the NSDUH survey, 47% of teens obtained free prescription drugs for nonmedical use from relatives or friends. Additionally, 6% reported obtaining the drugs without asking, and 20% said they bought them from a friend or relative. Serious or fatal consequences of prescription drug misuse or abuse by celebrities from Rush Limbaugh to Heath Ledger, have received extensive coverage in the press.

Prescription opioids can be abused using several routes, including ingestion, intravenous injection, and intranasal insufflation. Extended-release preparations of oxycodone can be crushed before injection or insufflation, leading to a more rapid onset of action but also an increased risk of overdose due to higher peak blood concentrations. Users present with the typical opioid syndrome, which includes mental status depression, miotic pupils, and hypoventilation.

Naloxone, an opioid receptor antagonist, is useful in the treatment of opioid overdose but should not be used indiscriminately. It should be reserved for patients with a respiratory rate of less than eight breaths per minute or significant hypopnea. Caution must also be used when giving naloxone to chronic opioid users because it can precipitate opioid withdrawal, pulmonary edema, and vomiting. Precipitating opioid withdrawal in a patient with a coingestant that causes persistent mental status depression can lead to vomiting and aspiration. A dose of 0.04 mg of intravenous naloxone should be given initially and then titrated to effect. Assisted ventilation should be performed while awaiting normalization of the patient’s ventilatory status.

An additional consideration when using naloxone is its short duration of action, which is often shorter than the drug it was administered to reverse. Patients must be closely monitored for the return of symptoms and some may require a continuous infusion of naloxone. If naloxone administration is contraindicated in a patient with respiratory depression, intubation and mechanical ventilation can be used to support the patient until the opioid has been eliminated.

Another concern is the possibility of toxic effects of other ingredients in combination products. Acetaminophen and aspirin and other nonsteroidal anti-inflammatory drugs are all available in combination analgesics. Tolerance of the opioid effects may cause patients to increase the number of pills they consume, leading to the ingestion of toxic amounts of coingredients, particularly acetaminophen. Care of these patients in the emergency department must include evaluation for acetaminophen and salicylate toxicity.

“PHARMING” IS ON THE RISE

Recently, the term pharming has been used to describe one setting in which prescription drug abuse occurs. Teens take drugs from their home medicine cabinets to parties where the pills are mixed together in bags or bowls. This mixture is referred to as “trail mix.” The drugs are then passed around and unknown substances are ingested indiscriminately. This practice is especially worrisome because polydrug ingestions may complicate patient evaluation and management. Warn parents to keep track of medications in their households and to discard old or unused prescriptions to prevent misappropriation.

“CHEESE” IS A DANGEROUS MIXTURE

Cheese is a combination of heroin with cough and cold preparations containing ingredients such as diphenhydramine, an antihistamine that can cause euphoria and hallucinations in overdose. Cheese gained national attention in 2005 when it was linked to the deaths of several teenagers in Dallas, Texas. The heroin concentration in cheese is typically 2% to 8%, compared to 30% found in black tar heroin (produced in Mexico and prevalent in the western United States). Cheese is called “starter heroin” and is thought to be targeted at young adolescents. It is snorted, not injected, and is packaged in small, inexpensive quantities usually costing between $2 and $10.

In the 2005 incidents, Dallas news agencies reported arrests in children between ages 10 and 16 for possession of cheese. In 2007, the Dallas County medical examiner reviewed cases from the preceding two years and suggested that as many as 17 deaths in teenagers were caused by cheese.

Clinical findings of cheese use are similar to those of other opioids, with the addition of an anticholinergic toxidrome due to the diphenhydramine. The anticholinergic toxidrome is classically associated with altered mental status (delirium and hallucinations); dry, flushed skin; large pupils; urinary retention; and hypoactive bowel sounds. The constellation of findings may vary based on the relative doses and the time course of intoxication. Different overdose symptoms may predominate at different times when several different drugs are ingested at once.

Naloxone may be considered, but it must be used with caution in patients not experiencing grave hypoventilation. Precipitation of opioid withdrawal, which induces vomiting, can lead to aspiration in a patient who is somnolent from an additional nonopioid ingestion. Physostigmine, a cholinesterase inhibitor, can also be considered for treatment of anticholinergic toxicity. However, it, too, must be used cautiously because it is relatively contraindicated in patients with mixed ingestions (who are unlikely to awaken with its administration), QRS widening, or asthma.

PHENYLETHYLAMINES ARE POPULAR AGAIN

Phenylethylamines are a category of amphetamine derivatives and include both naturally occurring compounds, such as mescaline, and synthetic “designer” drugs, such as methylenedioxymethamphetamine (MDMA or Ecstasy). Many of these amphetamine derivates were synthesized in the 1970s and were subsequently outlawed in the 1990s. Designer analogs have regained popularity as drugs of abuse among adolescents. Commonly seen examples are 4-bromo-2, 5-dimethoxyphenethylamine (2C-B), 2, 5-dimethoxy-4-ethylthiophenethylamine (2C-T-2), and 1-(8-bromobenzo[1, 2-b;4, 5-b’] difuran-4-yl)-2-aminopropane (Bromofly).

Although 2C-B is a schedule I drug, all designer amphetamine derivatives are illegal under the Federal Controlled Substance Analogue Act, which makes designer drugs illegal even if not specifically scheduled. Many of these compounds have an amphetamine-like structure with substitutions that enhance their ability to affect serotonin release, rather than the catecholamine (norepinephrine and dopamine) release typical of classical amphetamines. Many of these compounds are also structurally similar to serotonin and bind to the 5HT2 receptor.

The clinical effects of these drugs have elements of both catecholamine and serotonin neurotransmission. Amphetamine-like effects include headache, hypertension, tachycardia, agitation, and seizures. Serotongeric effects include euphoria, hallucinations, nausea, and vomiting. Deaths have been reported and are often due to hyperthermia. Treatment is supportive and symptomatic, consisting of antiemetics and sedation with benzodiazepines as needed.

One phenylethylamine that has become an important drug of misuse and abuse in adolescents is methylphenidate (Ritalin). Data from the DAWN study show a doubling in the number of emergency department mentions of methylphenidate from 2004 to 2005. Methylphenidate can be ingested, injected intravenously, and snorted intranasally. People who misuse methylphenidate—for example, those who take it without a prescription to stay awake or improve school performance—typically take the drug orally. Abusers attempting to get high often snort or inject crushed tablets.

Methylphenidate is not associated with hallucinations, and its effects are similar to those of amphetamine. Clinical findings include hypertension, tachycardia, chest pain, arrhythmias, and myocardial ischemia. Death has resulted from abuse. Treatment with benzodiazepines and supportive care are indicated.

SALVIA DIVINORUM IS PSYCHOTROPIC

Salvia divinorum is a sage plant that has psychotropic properties. It was used by Mazatec shamans in ancient Mexico for ritualistic purposes and also for the treatment of diarrhea, headache, and rheumatism.
The plant contains many different compounds, but the most active hallucinogenic ingredient is salvinorin A. This compound is a kappa-opioid receptor agonist. Salvinorin A does not affect serotonin receptors, making its mechanism of action unique when compared to that of other hallucinogens.

Salvia is readily available on the Internet. Preparations are typically leaves fortified with additional salvinorin extract and are marked as 53, 103, and so on to denote relative potency. The leaves can be smoked or chewed. There is very little gastric absorption, so users hold the juice in the oral cavity to allow for mucosal absorption. Reportedly, onset of hallucinations is slower this way but the experience is more intense compared to smoking. Smoking the leaves leads to immediate onset of hallucinations.

The effects typically last for 30 minutes or less and include euphoria, out-of-body experiences, hallucinations, uncontrolled laughter, and synesthesia. At least one suicide has been associated with Salvia use, although its role in the patient’s death is controversial. Parents of a teenager who committed suicide in Delaware attributed his depression to Salvia use and successfully lobbied for the outlawing of Salvia in that state.

Salvia divinorum is legal in all U.S. states except Delaware, Louisiana, and Missouri and in some European  countries. Maine and North Dakota have also passed legislation controlling Salvia divinorum. As of July 2007, legislative bills proposing regulatory controls on salvinorin A and/or Salvia divinorum are pending in Alabama, Alaska, California, Florida, Illinois, Iowa, New Jersey, New York, Ohio, Oregon, Pennsylvania, and Texas.

DEXTROMETHORPHAN USE IS INCREASING

Dextromethorphan (DXM) abuse among adolescents has been increasing. The drug is variously known as DXM, dex, skittles, triple C, and robo (after commonly abused preparations such as Coricidin Cough and Cold and Robitussin). A review of exposures reported to U.S. Poison Control Centers found a sevenfold increase in calls from 1999 to 2004. One survey found that 4% of 8th graders and 7% of 12th graders had used medications containing dextromethorphan to get high in the past year. 

Dextromethorphan can be taken in pill or liquid form. The therapeutic dose is up to 30 mg at a time, but abusers take hundreds or even a thousand milligrams at a time. “Agent Lemon” is a home extraction technique used to produce purified “crystal” dextromethorphan that can be freebased.

Dextromethorphan has complex receptor physiology. It is classified as an opioid and at high doses it binds to opioid receptors, leading to the opioid toxidrome. It also increases the release of and decreases the reuptake of serotonin, which can contribute to serotonin syndrome. This syndrome is caused by excessive stimulation of serotonin receptors and is characterized by a triad of hyperthermia, muscular rigidity, and altered mentation. Its major metabolite, dextrorphan, has an affinity for the phencyclidine (PCP) binding site of the N-methyl-D-aspartate (NMDA) receptor. The conversion of dextromethorphan to dextrorphan is catalyzed by debrisoquine 4-hydroxylase (CYP2D6), an enzyme that exhibits significant genetic polymorphism. Fast metabolizers have effects related to increased concentrations of dextrorphan and may have clinical symptoms similar to PCP intoxication. Slow metabolizers (5% to 10% of Caucasians) have effects related to increased dextromethorphan concentrations and experience more sedation and dysphoria.

Clinical findings of dextromethorphan overdose include euphoria, dysphoria, dissociative or out-of-body sensations, agitation, somnolence, hallucinations, ataxia, slurred speech, tachycardia, hypertension, diaphoresis, itching, and nystagmus. Dextromethorphan, like PCP, is classically associated with rotary nystagmus.

Patients abusing cough and cold preparations are at risk for poisoning from coingestants, including acetaminophen, guaifenesin, pseudoephedrine, antihistamines, and bromide. This is one reason why pure dextromethorphan products are sought and why freebasing is popular among some users.

Treatment is generally supportive. The efficacy of naloxone is questionable and case reports are contradictory regarding its benefits. Patients should be placed in a quiet room with minimal stimuli. Benzodiazepines can be given as needed for sedation.

EVOLVING ABUSE PATTERNS

The Internet allows teenagers rapid access to information about using new drugs of abuse, so adolescent patterns of drug misuse and abuse are continually evolving. Because drug misuse and abuse land many teens in the emergency department, practitioners need to be aware of drugs that are currently popular. Supportive medical care as well as psychosocial evaluation is essential for education and prevention of drug abuse in adolescents.

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