Signs of Drug Abuse

Amphetamines

Amphetamines were initially sold as a non-prescription appetite suppressant and rapidly became a favorite street drug (“pep pills”, “Bennies”). Crystallized methamphetamine (“crystal meth”, “crystal”, “ice”, “glass”, “tina”), an addictive stimulant with a high potential for abuse and dependence, produces an even stronger “rush” or “flash” when the powder is injected intravenously or inhaled; it is often supplied as small “rocks”. Oral ingestion of tablets (Desoxyn®; “speed”, “meth”, “crank”; “yaba” [with caffeine]) or snorting powder merely produces a profound sense of euphoria. Smoking the base form (“snot”) extends the duration of the “high” for up to 24 hours. Amphetamines can lead to reduced appetite, restlessness, insomnia, and increased or distorted sensations; on physical examination, there may tachypnea, tachycardia and hypertension as well as flushing, sweating, and even uncontrollable movements or shaking. “Speed freaks” (high-intensity abusers) progressively use the drug to remain euphoric, and high doses or chronic use often lead to xerostomia, xerosis, pruritus, acne excoriée and formication, along with dental caries and loss of teeth (“meth mouth”). “Tweaking”, continuous drug use without sleep for 3 to 15 days, is frequently associated with irritability, paranoia, violence, and frustration due to an inability to recreate the euphoric high.

Methylenedioxymethamphetamine (MDMA), also known as “ecstasy”, “E”, “Adam”, “X”, “XTC”, “molly”, “hug”, or “beans”, is a synthetic stimulant and hallucinogen with a chemical structure similar to methamphetamine. MDMA causes a reduction in the concentration of serotonin transporters (SERTs) within the brain , and brain injury caused by heavy, prolonged use of MDMA may be long-lasting . High doses can cause malignant hyperthermia, leading to rhabdomyolysis, renal failure, and cardiovascular collapse. Due in part to an increase in energy and a reduction of sexual inhibition, crystallized methamphetamine and MDMA are a staple at raves and PNP (“party and play”) parties and have been associated with unprotected, promiscuous sexual activity and an increased risk of contracting sexually transmitted diseases. More recently, “bath salts” (e.g. “Ivory Wave”, “Cloud 9”, “Vanilla Sky”) that contain mephedrone, methylenedioxypyrovalerone (MDPV), or other synthetic chemicals related to cathinone (an amphetamine-like stimulant found in the khat plant) have become popular; they are often snorted but can be injected, smoked or ingested orally.

Benzodiazepines

Benzodiazepines are among the most frequently prescribed medications in the US and the UK, where surveys indicate that ~10% of the population uses benzodiazepine sedatives/anxiolytics regularly. Although they are only mild euphoriants, benzodiazepines, in particular flunitrazepam (Rohypnol®; “roofies”), are commonly misused by polydrug addicts, alcoholics, and recreational drug users. Benzodiazepines are ingested (often with alcohol), snorted, or occasionally injected. They can lead to a decrease in alertness and a lack of coordination. Other side effects of benzodiazepines include disinhibition, anterograde amnesia, depression and confusion, and with an overdose or intravenous use, hypotension and hypoventilation.

Cannabis

Cannabis (“marijuana”, “pot”, “grass”, “herb”, “weed”, “bud”, “Mary Jane”) is the most frequently self-administered illicit drug. However, medical marijuana is currently legal in over 25 states in the US and recreational use is legal in seven states . Cannabis is a mixture of dried shredded leaves and flowers of the Cannabis sativa plant, which contains the chemical delta-9-tetrahydrocannabinol (THC). It is usually smoked as a cigarette or through a pipe or bong. Marijuana cigarettes may be laced with other drugs, such as crack or heroin. The minimal amount of THC required to produce a perceptible psychoactive effect is ~10 mcg/kg body weight. Altered perception may be accompanied by an impairment of concentration, psychomotor coordination, and/or short-term memory. Arteritis has also been reported , and it may represent a particular form of Buerger disease, with cannabis acting as a cofactor in young smokers.

In many countries, including the US, there has been an increase in the use of synthetic cannabinoids (“K2”, “Spice”, “Black Mamba”), which also bind the THC receptor, but may have increased vasoactive and psychoactive effects, including psychosis. Cannabinoids can be sprayed onto dried plants or inhaled via vaporizer electronic cigarettes.

Cocaine

Cocaine (“coke”, “blow”, “toot”, “flake”, “snow”, “bump”) is an alkaloid stimulant and topical anesthetic which is extracted from the leaves of the Erythroxylon coca shrub. Crack (“base”, “rock”, “hard rock”, “sugar block”), a freebase form of cocaine, is more addictive than heroin. It is produced by dissolving cocaine in water and baking soda and then heating the mixture until it crystallizes. Cocaine is injected or snorted, while crack is smoked.

In addition to Raynaud phenomenon, cocaine use has been associated with cutaneous small vessel vasculitis (leukocytoclastic vasculitis), necrotizing granulomatous vasculitis, acute generalized exanthematous pustulosis, and Stevens–Johnson syndrome . Its use can also lead to a number of cardiovascular side effects – Buerger disease, hypertensive crisis, myocardial or cerebral infarction, and ventricular arrhythmias. Cocaine adulterated with levamisole has been associated with neutropenia and ischemic vasculopathy with necrotizing purpura and ulceration (see below).

Gamma-Hydroxybutyrate

Gamma-hydroxybutyrate (GHB; “liquid X”, “liquid ecstasy”, “liquid G”, “fantasy”, “gamma-oh”), a “party drug”, is a rapid-acting CNS depressant popular among revelers for its relaxant, euphoric, and purported aphrodisiac properties. GHB can lead to a loss of consciousness as well as induce amnesia, and like flunitrazepam it is used as a “rape drug”. Because it reportedly promotes muscle mass and has been shown to elevate human growth hormone in vivo, GHB is also misused by bodybuilders.

Lysergic Acid Diethylamide

Lysergic acid diethylamide (“LSD”, “acid”), a hallucinogen, is manufactured from lysergic acid found in ergot, a fungus that grows on rye and other grains. It is often sold in single-dose (20 to 80 mcg) squares of blotter paper. LSD causes an altered experience of time, sense and memory, usually within 30–90 minutes after ingestion. Changes in auditory and visual perception (e.g. moving geometric patterns) are typical. In addition to pupil dilation and tachycardia, patients may develop sweating, sialorrhea, piloerection, and a strong metallic taste.

Opioids (Includes Opiates)

Also known as diacetylmorphine, heroin (“junk”, “smack”, “horse”, “H”, “scag”, “skag”), the fastest acting of all opiates, is three times more potent than morphine and accounts for much of the illicit opiate abuse in the US. Because of its lipid solubility, it crosses the blood–brain barrier rapidly, prompting a “rush” within 7 to 8 seconds after intravenous injection or 10–15 minutes after being snorted or smoked. There has been a growing tendency to sniff, snort (“shebang”) or smoke (“chase the dragon”) heroin rather than inject it intravenously (“shoot up”) or subcutaneously (“skin pop”). Opiate addicts may alternate injections of heroin and cocaine (crisscrossing) or inject highly addictive “speedballs” that combine the two drugs. Methadone, an oral synthetic opioid with a half-life between 24 and 48 hours, is widely used as a substitute for heroin in narcotic treatment programs and for chronic pain.

Opioids remain the leading cause of fatal overdoses, including methadone and other more commonly prescribed opioids. Fentanyl (“TNT”, “Apache”), a narcotic analgesic that is 50 to 100 times more potent than morphine, is particularly prone to overdosing. Heroin, which nowadays is less expensive than illegal prescription opioids, is increasingly being laced with fentanyl and its analog carfentanil such that first responders routinely carry naloxone (Narcan®). Buprenorphine, a more potent and longer-lasting analgesic than morphine, appears to act as a partial agonist of µ and κ opioid receptors, but tolerance with chronic use may not develop, presumably due to the lack of δ-agonist activity.

Pentazocine is an oral benzomorphan opioid antagonist with a lower risk of drug dependence than opiates, and ingestion of pentazocine may precipitate withdrawal symptoms in persons physically dependent on opioids. However, when tablets are crushed, diluted, and then injected in combination with the antihistamine tripelennamine (Pyribenzamine®), the euphoric effects are similar to those produced by heroin. The side effects are similar to those of morphine, but pentazocine may be associated with a greater risk of hallucinations. Severe necrosis and secondary infection of the skin and subcutaneous tissue, including underlying muscle, may develop at repeated injection sites of pentazocine.

Desomorphine (“krokodil”) is a fast-acting morphine derivative that is eight times more potent than morphine . The drug can be synthesized by combining red phosphorus from match strikers with codeine and iodine derived from over-the-counter medications; unfortunately, it is frequently contaminated with these and other agents . Injection of this “flesh-eating drug” can cause serious damage to the skin, blood vessels, bone and muscles, leading to limb amputation in long-term users . Of note, the tissue injury is due to iodine, phosphorus, and other toxic substances that remain after synthesis, not the opioid itself .