Close Calls with Club Drugs
http://www.100md.com
《新英格兰医药杂志》
Around midnight one night in 1999, I was radioed by the EMTs: they were bringing in two "drunk" college students. This was hardly an uncommon occurrence. Many a college student has been mortified to wake up in the emergency room looking into the eyes of a college administrator who knew that a stressful semester or a campus party could spell danger. Widespread alcohol abuse on college campuses and its sometimes fatal consequences have long raised alarm, and the signs and symptoms of cocaine or marijuana abuse are commonly known.
But there was something different about these students. Apparently healthy college men, they had been drinking at a party when the girlfriend of one noticed that they had disappeared. Worried, she went looking for them. She found them unconscious in the basement of the building, and she couldn't wake them. She might have left them there to sleep it off, but she called for help instead.
The EMTs who responded thought that the students were simply drunk, but the students' level of consciousness decreased alarmingly en route to the hospital. By the time they arrived, both young men were deeply comatose — unresponsive to all stimuli, including pain. As the EMTs were filling me in, I noticed that one of the patients had stopped breathing. Within a few minutes, both of them had to be intubated.
Had these men been left in the basement, they would have been brain-dead within about six minutes after they had stopped breathing, and their hearts would have stopped shortly thereafter. As it was, both required mechanical ventilation for the rest of the night.
What had these students taken? They didn't smell of alcohol. There were no track marks on their arms. There was no evidence of trauma or other disease. In fact, what was so alarming was how healthy they looked — they had simply stopped breathing.
None of their friends in the waiting room could tell me what drugs were involved, although there were murmurings of "G," "liquid E," and "vitamins" — street names for -hydroxybutyric acid (GHB), 3,4-methylenedioxymethamphetamine (MDMA, or ecstasy), and methamphetamine. Blood and urine drug screens were negative except for alcohol, but the level of ethanol was not high enough to cause respiratory arrest. These patients were not alcoholics, not IV drug abusers. They were student athletes nearing graduation from college with the whole world ahead of them.
As an emergency physician, I had watched the evolution — and treated the clinical consequences — of the abuse of legal and illegal drugs from the hallucinogens of the 1960s to the stimulants and opiates of the 1970s and the cocaine of the 1980s. Now I was encountering the difficulties of diagnosing abuse of the so-called club drugs — which, unfortunately, many people still erroneously believe to be harmless.
The most commonly used club drugs are GHB, MDMA, flunitrazepam, and ketamine. Instructions for making them with the use of chemicals found in household products, over-the-counter medications, and prescription drugs can be found on Internet sites, rendering them accessible and inexpensive. They are also potentially deadly.
In this case, I believe that the culprit was GHB (discussed by Snead and Gibson in this issue of the Journal, pages 2721–2732). Clear, odorless, tasteless, and thought to be an aphrodisiac and an amnesic, GHB unfortunately makes a perfect date-rape drug. But the euphoria that begins 20 to 30 minutes after ingestion can quickly evolve into more toxic effects, including dizziness, nausea and vomiting, myoclonic jerks, confusion, agitation, hallucination, and seizure. In combination with alcohol, GHB can cause decreased respiratory drive, coma, and death. There is currently no metabolite that can be measured on routine toxicology screens, so although some laboratories can now test for GHB, the results are not available on an emergency basis.
I don't know whether these students are aware of how close they came to dying. Because they arrived at the hospital when they did, they were able to walk out the following day, remembering little or nothing of the entire event. Given their friends' comments, their profound respiratory depression, the duration of the effects, and the subsequent amnesia, my guess is that they combined GHB with alcohol. But the amnesia made it impossible to get an accurate history.
Clearly, alcohol, tobacco, and marijuana are not the only temptations out there for our children. Club drugs can be taken in pill or liquid form — no snorting, smoking, or needles required. Given the deceptively innocuous qualities of these drugs, it is important to raise awareness of their potentially devastating effects.(Cynthia G. McGinn, M.D.)
But there was something different about these students. Apparently healthy college men, they had been drinking at a party when the girlfriend of one noticed that they had disappeared. Worried, she went looking for them. She found them unconscious in the basement of the building, and she couldn't wake them. She might have left them there to sleep it off, but she called for help instead.
The EMTs who responded thought that the students were simply drunk, but the students' level of consciousness decreased alarmingly en route to the hospital. By the time they arrived, both young men were deeply comatose — unresponsive to all stimuli, including pain. As the EMTs were filling me in, I noticed that one of the patients had stopped breathing. Within a few minutes, both of them had to be intubated.
Had these men been left in the basement, they would have been brain-dead within about six minutes after they had stopped breathing, and their hearts would have stopped shortly thereafter. As it was, both required mechanical ventilation for the rest of the night.
What had these students taken? They didn't smell of alcohol. There were no track marks on their arms. There was no evidence of trauma or other disease. In fact, what was so alarming was how healthy they looked — they had simply stopped breathing.
None of their friends in the waiting room could tell me what drugs were involved, although there were murmurings of "G," "liquid E," and "vitamins" — street names for -hydroxybutyric acid (GHB), 3,4-methylenedioxymethamphetamine (MDMA, or ecstasy), and methamphetamine. Blood and urine drug screens were negative except for alcohol, but the level of ethanol was not high enough to cause respiratory arrest. These patients were not alcoholics, not IV drug abusers. They were student athletes nearing graduation from college with the whole world ahead of them.
As an emergency physician, I had watched the evolution — and treated the clinical consequences — of the abuse of legal and illegal drugs from the hallucinogens of the 1960s to the stimulants and opiates of the 1970s and the cocaine of the 1980s. Now I was encountering the difficulties of diagnosing abuse of the so-called club drugs — which, unfortunately, many people still erroneously believe to be harmless.
The most commonly used club drugs are GHB, MDMA, flunitrazepam, and ketamine. Instructions for making them with the use of chemicals found in household products, over-the-counter medications, and prescription drugs can be found on Internet sites, rendering them accessible and inexpensive. They are also potentially deadly.
In this case, I believe that the culprit was GHB (discussed by Snead and Gibson in this issue of the Journal, pages 2721–2732). Clear, odorless, tasteless, and thought to be an aphrodisiac and an amnesic, GHB unfortunately makes a perfect date-rape drug. But the euphoria that begins 20 to 30 minutes after ingestion can quickly evolve into more toxic effects, including dizziness, nausea and vomiting, myoclonic jerks, confusion, agitation, hallucination, and seizure. In combination with alcohol, GHB can cause decreased respiratory drive, coma, and death. There is currently no metabolite that can be measured on routine toxicology screens, so although some laboratories can now test for GHB, the results are not available on an emergency basis.
I don't know whether these students are aware of how close they came to dying. Because they arrived at the hospital when they did, they were able to walk out the following day, remembering little or nothing of the entire event. Given their friends' comments, their profound respiratory depression, the duration of the effects, and the subsequent amnesia, my guess is that they combined GHB with alcohol. But the amnesia made it impossible to get an accurate history.
Clearly, alcohol, tobacco, and marijuana are not the only temptations out there for our children. Club drugs can be taken in pill or liquid form — no snorting, smoking, or needles required. Given the deceptively innocuous qualities of these drugs, it is important to raise awareness of their potentially devastating effects.(Cynthia G. McGinn, M.D.)