Pearls:

The legalization of marijuana may be problematic in that the synthetic forms of marijuana may be chemically manipulated and more dramatic presentations than classically thought of.

Drugs that get abused are often drugs that are easy to access and are popular with peer groups.

How has the use of drugs of abuse changed? It is more about opportunity than anything else. For example, historical drugs of abuse include marijuana, cocaine and speed; these drugs are still being abused but there are newer versions of these drugs and novel methods of using them. Which drugs are abused differs significantly depending on social demographics and geographic location.

How do drugs of abuse vary by age? Generally speaking, middle school children are experimenting with drugs for the first time. While there are always extreme situations in which children this age are snorting or injecting, more often, middle schoolers will experiment by drinking teas laced with drugs (for example, jimson weed tea) and/or smoking. High school students are more frequently using benzodiazepines and a whole class of sedative hypnotics, even during school.

While these children may not be trying to intentionally harm themselves, there may be some underlying issue prompting them to act this way. This should be explored; specifically addressing the question of suicidality.

Open continuous dialogues should be had with children regarding drugs of abuse, because if the only information about these substances come from peers or the internet, there will be a lot of misinformation.

How and why is jimson weed abused? Jimson weed is a ubiquitous and completely legal plant. It has a characteristic bell shaped white or yellow flower that often grows on the side of the freeway. To abuse, the petals, leaves or seeds are placed into boiling water and steeped for tea. Jimson weed contains scopolamine analogues, similar to atropine and has anticholinergic effects such as confusion, mild hallucinations, fevers and flushing. It would be like taking a lot of diphenhydramine or straight belladona.

What about the use of bath salts? Bath salts synthetically made drugs derived from the alkaloids, cathinone and cathine, found in the khat (also spelled ‘qat’) plant as a base. The most common synthetically made bath salt is mephedrone. They are called bath salts for their oily, crystal appearance. They can be abused in almost any form; some examples include dissolving the salts under your tongue or smoking. Bath salts are sold as the final product in places such as smoke shops. There are about 200 different names for bath salts and some are marketed as “plant food.” There are many jurisdictions that have banned the sale of bath salts; but not entirely and shops can find loopholes to legally sell these synthetic drugs.

A child who has abused bath salts may present as a mixed picture. There is an amphetamine-like effect, a cocaine-like effect, a PCP-like effect and even an LSD-like effect.

What is the purple drink? This is essentially a phenergan (promethazine)-codeine preparations. On the streets it is also called “purple drank” or “purple crank.”

Are over the counter medications being abused and/or regulated? One of the most prominent changes that occured within the last few years is that dextromethorphan is now being sold essentially as a behind the counter drug. People have been abusing this medication for a long time; for example, in the 1980s it was popular to do “Robo-Shots” or shots of Robitussin (which contains dextromethorphan). Now that these medications come in pill form and are more palatable, there has been a recreational increase in the use of dextromethorphan. Interestingly, there is also a behind the counter status for the air sprays used to clean electronic equipment, such as keyboards. These sprays contain compressed air and hydrocarbons and people use these to get high.

How should we can counsel patients and families about drugs of abuse? There is a lot of variability from region to region, so it is important to know what is prevalent in your specific practice area. Drug abuse, as stated earlier has a lot to do with access and popularity. In the eastern part of the US, for example, cocaine is still popular. In the western part of the US, amphetamine and synthetic marijuana use is popular. Inhalants are a nationwide problem.

Children often have their first exposure to drugs in social situations. At parties, for example, kids may see the drugs of abuse having sympathomimetic effects which can be life threatening and should be discussed.

How might the legalization of recreational marijuana in some states affect its abuse? Simply, marijuana is not marijuana anymore. That is there are more potent versions and synthetic varieties. The biochemical alterations can be scary as the drug can be dramatically chemically altered and the effects are different. For example, seizures and high blood pressure may result which are not effects expected from conventional marijuana use.