By Kim Vo
February 14, 2000
Photo: Eyewire

Ecstasy in California, roofies in Colorado, GHB in Texas. Illicit drug use remains a significant health problem in the United States, particularly among teen-agers, and continues to present diagnostic and treatment challenges to nurses and emergency room staff who see patients when the party's over.

While alcohol and marijuana remain longtime favorites, four so-called "designer drugs" – ecstasy, ketamine, GHB (gamma-hydroxybutyrate), and Rohypnol – are topping the party circuit. "They change a lot," said George Velianoss, RN, deputy executive director of nursing of the Emergency Nurses Association in Des Plaines, Ill. "Each region of the country seems to have its own goodies."

Difficult diagnoses

Nurses have learned to listen for two words: "the drug." "We have girls who come in saying they've been given 'the drug,' " said Terry Landgraff, MS, RN, chief nursing officer at St. Luke's Medical Center in Tempe, Ariz.

"The drug" they are referring to is flunitrazepam (Rohypnol), also known as roofies, the forget-me pill, and the date rape drug. The tranquilizer can induce blackouts and coma, and earned its reputation after being used in connection with sexual assaults in which pills were ground up and slipped into drinks.

Last month, Congress toughened laws for possessing or selling so-called date rape drugs like Rohypnol and GHB by passing the Hillory J. Farias and Samantha Reid Date-Rape Drug Prohibition Act of 1999. The act was named for two girls who died after roofies were placed in their sodas. President Clinton is expected to sign the bill.

Despite heightened recognition after the government's action, Elda Ramirez, MSN, RN, assistant professor of clinical nursing at the University of Texas in Houston, warns that Rohypnol abuse may be underreported since rape victims are not routinely tested for drugs.

Ketamine is the drug of choice in San Diego since it can be legally—and cheaply—purchased in Mexico. Classified as a dissociative anesthetic, ketamine hydrocholoride (Ketalar) induces a sense of invincibility, numbness, a blank stare, rapid and involuntary eye movements, and an exaggerated gait. Overdosing can lead to extreme paranoia and violent hostility.

The most widely abused party drug remains methylenedioxymethamphetamine (MDMA) or ecstasy—also known as XTC, clarity, adam, and lover's speed. Swallowed in a drink or taken as a pill, MDMA is touted for its aphrodisiac effects and feelings of euphoria. Long-term use can lead to decreased levels of serotonin, ataxia, sweating, and blurred vision.

Statistics on illicit drug use among teen-agers are scarce, but one recent report does show a rise in ecstasy use among older teen-agers. In "Monitoring the Future," the University of Michigan Institute for Social Research found that ecstasy use among 10th-grade students rose from 3.3 percent in 1998 to 4.4 percent in 1999. Among high school seniors, the increase was even higher: 5.6 percent in 1999, compared to 3.6 percent in 1998.

Club clothes a tip-off

San Francisco also has seen a rise in GHB cases over the last five years, said Karl Sporer, MD, associate clinical professor at San Francisco General Hospital.

Originally marketed as a muscle builder, GHB has proven to be a powerful depressant. Users swallow a few tablespoons of the salty solution or down it like a shot of alcohol. The effect usually lasts three hours with little or no hangover effect.

But those who take too much can fall into a coma with extremely shallow breathing patterns. "If you've never seen this before, you'll probably do a CAT scan and keep them on a ventilator—that's acceptable," said Sporer, who usually is tipped off to GHB use when patients arrive in groups wearing club clothes. In cases where GHB use is certain, healthcare workers should observe the patient closely and monitor breathing, Sporer said.

Many times, patients aren't screened for party drugs because both they and the hospital staff assume they're suffering from excessive alcohol intake—for instance, the ketamine stupor can seem like drunkenness or psychiatric illness. Furthermore, there's no one simple test that shows individual party drugs in the body—Rohypnol and diazepam (Valium), for example, appear as benzodiazapine in tests.

Many times the only tip-off to illicit drug use is the testimony of the patients themselves, which can be sketchy or unreliable. Furthermore, patients often are hesitant to report illicit drug use. "Unless kids say, 'They put something in my drink,' staff usually assume it's alcohol and they're not screened," Ramirez said.

Observation the key

Although the effects of party drugs vary, the treatment is often the same: observation. In most cases, nurses are advised to keep watch and make sure patients don't leave the hospital until they're alert and awake, Ramirez said.

In ecstasy cases, nurses should note patients' heart rates and make certain they aren't suffering from hyperthermia, Sporer said. "Ravers" are particularly susceptible because parties take place in enclosed, crowded places where they are likely to get overheated.

In extreme cases, Sporer said, patients may need to be physically restrained or given an anti-anxiety medication.

At Florida Hospital Medical Center in Orlando, Michael Cox, RN, said that for ketamine overdoses, staff routinely give patients high-flow oxygen and monitor their vital signs. Recommended treatment also can include benzodiazepines to reduce hallucinations and diazepam for seizures, he said.