MDMA reconsidered

Designer Drugs of Abuse

Designer drugs of abuse represent a major health risk to those who use them. The toxic effects of these agents are very dangerous when they are correctly identified, but they are especially dangerous because they are often misidentified by emergency room personnel. The three groups of designer drugs are the opiates, amphetamine derivatives and phencyclidine derivatives. Amphetamine derivatives such as MDMA and MDA can cause fatal sequelae including hyperthermia, hypertension, and seizures. No specific antidote exists for these agents. Therefore, their widespread use in certain areas is a major concern. The opiate derivatives M PPP, MPTP and the fentanyl analogues produce a wide range of toxic effects. These agents are much more potent than heroin, and are sometimes sold as heroin unknowingly to the user. The results have been catastrophic, with many fatalities. Arylhexylamines such as phencyclidine and ketamine are becoming more popular as agents of abuse. These drugs may result in fatal toxicity resulting from cardiac arrest, hypertensive emergency, or status epilepticus. Familiarity with the signs and symptoms of toxicity from the designer drugs will expedite the care of these patients.

Clinical features and management of intoxication due to hallucinogenic drugs

Hallucinogenic drugs are unique in that they produce the desired hallucinogenic effects at what are considered non-toxic doses. The hallucinogenic drugs can be categorised into 4 basic groups: indole alkaloid derivatives, piperidine derivatives, phenylethylamines and the cannabinols. The drugs reviewed include lysergic acid diethylamide (LSD), phencyclidine (PCP), cocaine, amphetamines, opiates, marijuana, psilocybin, mescaline, and 'designer drugs.' Particularly noteworthy is that each hallucinogen produces characteristic behavioural effects which are related to its serotonergic, dopaminergic or adrenergic activity. Cocaine produces simple hallucinations, PCP can produce complex hallucinations analogous to a paranoid psychosis, while LSD produces a combination of hallucinations, pseudohallucinations and illusions. Dose relationships with changes in the quality of the hallucinatory experience have been described with amphetamines and, to some extent, LSD. Flashbacks have been described with LSD and alcohol. Management of the intoxicated patient is dependent on the specific behavioural manifestation elicited by the drug. The principles involve differentiating the patient's symptoms from organic (medical or toxicological) and psychiatric aetiologies and identifying the symptom complex associated with the particular drug. Panic reactions may require treatment with a benzodiazepine or haloperidol. Patients with LSD psychosis may require an antipsychotic. Patients exhibiting prolonged drug-induced psychosis may require a variety of treatments including ECT, lithium and l-5-hydroxytryptophan.