Inhalants. How Are Inhalants Abused? Abusers of inhalants breathe them in through the nose or mouth in a varie- ty of ways (known as huffing ).

Transcription

1 Inhalants Many products readily found in the home or workplace such as spray paints, markers, glues, and cleaning fluids contain volatile substances that have psychoactive (mind- altering) properties when inhaled. People do not typically think of these products as drugs because they were never intended for that purpose. However, these products are some- times abused in that way. They are especially (but not exclusively) abused by young children and adoles- cents, and are the only class of sub- stance abused more by younger than by older teens. Grade High- School Students Repor:ng Having Ever Used Inhalants 8th 10th 12th Definition Although other abused drugs can be inhaled, the term inhalants is reserved for the wide variety of substances including solvents, aerosols, gases, and nitrites that are rarely, if ever, taken via any other route of administration. (See below for a list of examples.) may sniff or snort fumes from a con- tainer or dispenser (such as a glue bottle or a marking pen), spray aero- sols (such as computer cleaning dust- ers) directly into their nose or mouth, or place a chemical- soaked rag in their mouth. Abusers may also inhale fumes from a balloon or a plastic or paper bag. Although the high produced by inhalants usually lasts just a few minutes, abusers often try to prolong it by continuing to inhale repeatedly over several hours. 0.00% 5.00% 10.00% 15.00% Source: University of Michigan, 2011 Monitoring the Future Study. Survey data can be found at How Are Inhalants Abused? Abusers of inhalants breathe them in through the nose or mouth in a varie- ty of ways (known as huffing ). They Inhalants September 2012 Page 1 People tend to abuse different inhal- ant products at different ages. New users ages most commonly abuse glue, shoe polish, spray paints, gasoline, and lighter fluid. New users ages most commonly abuse ni- trous oxide or whippets. Adults most commonly abuse a class of in- halants known as nitrites (such as amyl nitrites or poppers ).

2 How Do Inhalants Affect the Brain? Most abused inhalants other than ni- trites depress the central nervous sys- tem in a manner not unlike alcohol. The effects are similar including slurred speech, lack of coordination, euphoria, and dizziness. Inhalant abusers may also experience light- headedness, hallucinations, and delu- sions. With repeated inhalations, many users feel less inhibited and less in control. Some may feel drowsy for several hours and experience a linger- ing headache. Products Abused as Inhalants Volatile solvents liquids that vaporize at room temperature: Industrial or household products, including paint thinners or removers, degreasers, dry- cleaning fluids, gasoline, and lighter fluid Art or office supply solvents, including correc- tion fluids, felt- tip marker fluid, electronic con- tact cleaners, and glue Aerosols sprays that contain propellants and solvents: Household aerosol propellants in items such as spray paints, hair or deodorant sprays, fabric protector sprays, aerosol computer cleaning products, and vegetable oil sprays Unlike other types of inhalants, nitrites enhance sexual pleasure by dilating and relaxing blood vessels. Although it is not very common, ad- diction to inhalants can occur with re- peated abuse. What Are the Other Health Effects of Inhalants? Chemicals found in different types of inhaled products may produce a vari- ety of other short- term effects, such as nausea or vomiting, as well as more serious long- term consequences. The- se may include liver and kidney dam- age, hearing loss, or bone marrow damage. Effects may also include loss of coordination and limb spasms due to damage to myelin a protective sheathing around nerve fibers that helps nerves transmit messages in the brain and peripheral nervous system. Inhalants can also cause brain damage by cutting off oxygen flow to the brain. Inhalants can even be lethal. Sniffing highly concentrated amounts of the chemicals in solvents or aerosol sprays can directly cause heart failure within minutes. This syndrome, known as sudden sniffing death, can result from a single session of inhalant use by an otherwise healthy young Inhalants September 2012 Page 2 Gases found in household or commercial prod- ucts and used as medical anesthetics: Household or commercial products, including butane lighters and propane tanks, whipped cream aerosols or dispensers ( whippets ), and refrigerant gases Medical anesthetics, such as ether, chloro- form, halothane, and nitrous oxide ( laughing gas ) Nitrites used primarily as sexual enhancers: Organic nitrites are volatiles that include cy- clohexyl, butyl, and amyl nitrites, commonly known as poppers. Amyl nitrite is still used in certain diagnostic medical procedures. When marketed for illicit use, organic nitrites are of- ten sold in small brown bottles labeled as vid- eo head cleaner, room odorizer, leather cleaner, or liquid aroma. person. High concentrations of inhal- ants may also cause death from suffo- cation, especially when inhaled from a paper or plastic bag or in a closed ar- ea. Even when using aerosols or vola- tile products for their legitimate pur- poses like painting or cleaning, it is wise to do so in a well- ventilated room or outdoors. Nitrites are a special class of inhalants that are abused to enhance sexual pleasure and performance. They can be associated with unsafe sexual prac- tices that increase the risk of contract- ing and spreading infectious diseases like HIV/AIDS and hepatitis.

3 Learn More For additional information on inhal- ants and inhalant abuse, please see ons/research- reports/inhalant- abuse Inhalants September 2012 Page 3

4 Synthetic Cathinones ( Bath Salts ) The term bath salts refers to an emerging family of drugs containing one or more synthetic chemicals related to cathinone, an amphetamine-like stimulant found naturally in the Khat plant. they are sold online and in drug paraphernalia stores under a variety of brand names, such as Ivory Wave," "Bloom," "Cloud Nine," "Lunar Wave," "Vanilla Sky," "White Lightning," and Scarface. Reports of severe intoxication and dangerous health effects associated with use of bath salts have made these drugs a serious and growing public health and safety issue. The synthetic cathinones in bath salts can produce euphoria and increased sociability and sex drive, but some users experience paranoia, agitation, and hallucinatory delirium; some even display psychotic and violent behavior, and deaths have been reported in several instances. In Name Only The synthetic cathinone products marketed as bath salts to evade detection by authorities should not be confused with products such as Epsom salts that are sold to improve the experience of bathing. The latter have no psychoactive (drug-like) properties. Bath salts typically take the form of a white or brown crystalline powder and are sold in small plastic or foil packages labeled not for human consumption. Sometimes also marketed as plant food or, more recently, as jewelry cleaner or phone screen cleaner How Are Bath Salts Abused? Bath Salts November 2012 Page 1 Bath salts are typically taken orally, inhaled, or injected, with the worst outcomes being associated with snorting or needle injection. How Do Bath Salts Affect the Brain? Common synthetic cathinones found in bath salts include 3,4- methylenedioxypyrovalerone (MDPV), mephedrone ( Drone, Meph, or Meow Meow ), and methylone, but there are many others. Much is still unknown

5 An Evolving Threat When bath salts emerged at the end of the last decade, they rapidly gained popularity in the U.S. and Europe as legal highs. In October 2011, the U.S. Drug Enforcement Administration placed three common synthetic cathinones under emergency ban pending further investigation, and in July 2012, President Obama signed legislation permanently making two of them mephedrone and MDPV illegal, along with several other synthetic drugs often sold as marijuana substitutes ( Spice ). Although the new law also prohibits chemically similar analogues of the named drugs, manufacturers are expected to respond by creating new drugs different enough from the banned substances to evade legal restriction. After mephedrone was banned in the United Kingdom in 2010, for example, a chemical called naphyrone quickly replaced it, and is now being sold as jewelry cleaner under the brand name Cosmic Blast. about how these substances affect the human brain, and each one may have somewhat different properties. Chemically, they are similar to amphetamines (such as methamphetamine) as well as to MDMA (ecstasy). The energizing and often agitating effects reported in people who have taken bath salts are consistent with other drugs like amphetamines and cocaine that raise the level of the neurotransmitter dopamine in brain circuits regulating reward and movement. A surge in dopamine in these circuits causes feelings of euphoria and increased activity. A similar surge of the transmitter norepinephrine can raise heart rate and blood pressure. Bath salts have been marketed as cheap (and until recently, legal see Box) substitutes for those stimulants. A recent study found that MDPV the most common synthetic cathinone found in the blood and urine of patients admitted to emergency departments after bath salts ingestion raises brain dopamine in the same manner as cocaine but is at least 10 times more potent. The hallucinatory effects often reported in users of bath salts are consistent with other drugs such as MDMA or LSD that raise levels of another neurotransmitter, serotonin. A recent analysis of the effects in rats of mephedrone and methylone showed that these drugs raised levels of serotonin in a manner similar to MDMA. What Are the Other Health Effects of Bath Salts? Bath salts have been linked to an alarming surge in visits to emergency departments and poison control centers across the country. Common reactions reported for people who have needed medical attention after using bath salts include cardiac symptoms (such as racing heart, high blood pressure, and chest pains) and psychiatric symptoms including paranoia, hallucinations, and panic attacks. Patients with the syndrome known as excited delirium from taking bath salts also may have dehydration, breakdown of skeletal muscle tissue, and kidney failure. Intoxication from several synthetic cathinones including MDPV, mephedrone, methedrone, and butylone has proved fatal in several instances. Early indications are that synthetic cathinones have a high abuse and addiction potential. In a study of the rewarding and reinforcing effects of MDPV, rats showed self-administration patterns and Bath Salts November 2012 Page 2

6 escalation of drug intake nearly identical to methamphetamine. Bath salts users have reported that the drugs trigger intense cravings (or a compulsive urge to use the drug again) and that they are highly addictive. Frequent consumption may induce tolerance, dependence, and strong withdrawal symptoms when not taking the drug. The dangers of bath salts are compounded by the fact that these products may contain other, unknown ingredients that may have their own harmful effects. Also, drug users who believe they are purchasing other drugs such as ecstasy may be in danger of receiving synthetic cathinones instead. For example, mephedrone has been found commonly substituted for MDMA in pills sold as ecstasy in the Netherlands. Learn More For additional information on bath salts, please see ions/drug-profiles/synthetic-cathinones Bath Salts November 2012 Page 3

7 Cocaine Cocaine is a powerfully addictive stimulant drug. The powdered hydrochloride salt form of cocaine can be snorted or dissolved in water and then injected. Crack is the street name given to the form of cocaine that has been processed to make a rock crystal, which, when heated, produces vapors that are smoked. The term crack refers to the crackling sound produced by the rock as it is heated. How Is Cocaine Abused? Three routes of administration are commonly used for cocaine: snorting, injecting, and smoking. Snorting is the process of inhaling cocaine powder through the nose, where it is absorbed into the bloodstream through the nasal tissues. Injecting is the use of a needle to insert the drug directly into the bloodstream. Smoking involves inhaling cocaine vapor or smoke into the lungs, where absorption into the bloodstream is as rapid as it is by injection. All three methods of cocaine abuse can lead to addiction and other severe health problems, including increasing the risk of contracting HIV/AIDS and other infectious diseases. The intensity and duration of cocaine s effects which include increased energy, reduced fatigue, and mental alertness depend on the route of drug administration. The faster cocaine is absorbed into the bloodstream and delivered to the brain, the more intense the high. Injecting or smoking cocaine produces a quicker, stronger high than snorting. On the other hand, faster absorption usually means shorter duration of action: the high from snorting cocaine may last 15 to 30 minutes, but the high from smoking may last only 5 to 10 minutes. In order to sustain the high, a cocaine abuser has to administer the drug again. For this reason, cocaine is sometimes abused in binges taken repeatedly within a relatively short period of time, at increasingly higher doses. How Does Cocaine Affect the Brain? Cocaine is a strong central nervous system stimulant that increases levels of dopamine, a brain chemical (or neurotransmitter) associated with pleasure and movement, in the brain s reward circuit. Certain brain cells, or neurons, use dopamine to communicate. Updated March 2010 Page 1 of 5

8 Normally, dopamine is released by a neuron in response to a pleasurable signal (e.g., the smell of good food), and then recycled back into the cell that released it, thus shutting off the signal between neurons. Cocaine acts by preventing the dopamine from being recycled, causing excessive amounts of the neurotransmitter to build up, amplifying the message to and response of the receiving neuron, and ultimately disrupting normal communication. It is this excess of dopamine that is responsible for cocaine s euphoric effects. With repeated use, cocaine can cause long-term changes in the brain s reward system and in other brain systems as well, which may eventually lead to addiction. With repeated use, tolerance to the cocaine high also often develops. Many cocaine abusers report that they seek but fail to achieve as much pleasure as they did from their first exposure. Some users will increase their dose in an attempt to intensify and prolong the euphoria, but this can also increase the risk of adverse psychological or physiological effects. What Adverse Effects Does Cocaine Have on Health? Abusing cocaine has a variety of adverse effects on the body. For example, cocaine constricts blood vessels, dilates pupils, and increases body temperature, heart rate, and blood pressure. It can also cause headaches and gastrointestinal complications such as abdominal pain and nausea. Because cocaine tends to decrease appetite, chronic users can become malnourished as well. Different methods of taking cocaine can produce different adverse effects. Regular intranasal use (snorting) of cocaine, for example, can lead to loss of the sense of smell; nosebleeds; problems with swallowing; hoarseness; and a chronically runny nose. Ingesting cocaine can cause severe bowel gangrene as a result of reduced blood flow. Injecting cocaine can bring about severe allergic reactions and increased risk for contracting HIV/AIDS and other blood-borne diseases. Binge-patterned cocaine use may lead to irritability, restlessness, and anxiety. Cocaine abusers can also experience severe paranoia a temporary state of full-blown paranoid psychosis in which they lose touch with reality and experience auditory hallucinations. Regardless of the route or frequency of use, cocaine abusers can experience acute cardiovascular or cerebrovascular emergencies, such as a heart attack or stroke, which may cause sudden death. Cocaine-related deaths are often a result of cardiac arrest or seizure followed by respiratory arrest. Updated March 2010 Page 2 of 5

9 Added Danger: Cocaethylene Polydrug use use of more than one drug is common among substance abusers. When people consume two or more psychoactive drugs together, such as cocaine and alcohol, they compound the danger each drug poses and unknowingly perform a complex chemical experiment within their bodies. Researchers have found that the human liver combines cocaine and alcohol to produce a third substance, cocaethylene, which intensifies cocaine s euphoric effects. Cocaethylene is associated with a greater risk of sudden death than cocaine alone. 1 What Treatment Options Exist? Behavioral interventions particularly, cognitive-behavioral therapy have been shown to be effective for decreasing cocaine use and preventing relapse. Treatment must be tailored to the individual patient s needs in order to optimize outcomes this often involves a combination of treatment, social supports, and other services. Currently, there are no FDA-approved medications for treating cocaine addiction; thus, developing a medication to treat cocaine and other forms of addiction remains one of NIDA s top research priorities. Researchers are seeking to develop medications that help alleviate the severe craving associated with cocaine addiction, as well as medications that counteract cocaine-related relapse triggers, such as stress. Several compounds are currently being investigated for their safety and efficacy, including a vaccine that would sequester cocaine in the bloodstream and prevent it from reaching the brain. Current research suggests that while medications are effective in treating addiction, combining them with a comprehensive behavioral therapy program is the most effective method to reduce drug use in the long term. How Widespread Is Cocaine Abuse? Monitoring the Future Survey According to the 2009 Monitoring the Future survey a national survey of 8th, 10th-, and 12th-graders there were continuing declines reported in the use of powder cocaine, with past-year usage levels reaching their lowest point since the early 1990s. Significant declines in use were measured from 2008 to 2009 among 12th-graders across all three survey categories: lifetime use decreased from Updated March 2010 Page 3 of 5

10 7.2 percent to 6.0 percent; past-year use dropped from 4.4 percent to 3.4 percent; and past-month use dropped from 1.9 percent to 1.3 percent. Survey measures showed other positive findings among 12th-graders as well; their perceived risk of harm associated with powder cocaine use increased significantly during the same period. Additionally, survey participants in the 10th grade reported significant changes, with past-month use falling from 1.2 percent in 2008 to 0.9 percent in Use of Cocaine by Students 2009 Monitoring the Future Survey 8th Grade 10th Grade 12th Grade Lifetime 2.6% 4.6% 6.0% Past Year 1.6% 2.7% 3.4% Past Month 0.8% 0.9% 1.3% Crack Cocaine Use by Students 2009 Monitoring the Future Survey 8th Grade 10th Grade 12th Grade Lifetime 1.7% 2.1% 2.4% Past Year 1.1% 1.2% 1.3% Past Month 0.5% 0.4% 0.6% National Survey on Drug Use and Health (NSDUH) According to the 2008 National Survey on Drug Use and Health, the estimated percentage of persons aged 12 or older who used cocaine in the past month (0.7 percent) was similar to the percentage in 2007 and However, the percentage of past-month crack users in 2008 (0.1 percent of the population) was lower than in 2007 and all other years going back to 2002, with the exception of From 2002 to 2008, rates of past-month cocaine use among youth aged 12 to 17 declined significantly, from 0.6 percent to 0.4 percent. Past-month cocaine use also dropped significantly among young adults aged 18 to 25 during this time period, from 2.0 percent to 1.5 percent. Significant declines in the number or percentage of past-year cocaine initiates were also estimated among several age groups measured, including persons 12 or older and those aged 18 to 25. The percentage of past-year initiates also dropped significantly from 2007 to 2008 for crack use among the age group. Updated March 2010 Page 4 of 5

11 Other Information Sources For additional information on cocaine, please refer to the following sources on NIDA s Web site, For street terms searchable by drug name, cost and quantities, drug trade, and drug use, visit gov/streetterms/default.asp. Cocaine: Abuse and Addiction Research Report Series Various issues of NIDA Notes (search by cocaine or crack ) Data Sources These data are from the 2009 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan s Institute for Social Research. The survey has tracked 12th-graders illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are on line at Lifetime refers to use at least once during a respondent s lifetime. Past year refers to use at least once during the year preceding an individual s response to the survey. Past month refers to use at least once during the 30 days preceding an individual s response to the survey. NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans aged 12 and older conducted by the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. This survey is available on line at and can be ordered by phone from NIDA at Reference 1 Harris DS, et al. The pharmacology of cocaethylene in humans following cocaine and ethanol administration. Drug Alcohol Depend 72(2): , Updated March 2010 Page 5 of 5

12 Heroin Heroin is an opiate drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as black tar heroin. How Is Heroin Abused? Heroin can be injected, snorted/sniffed, or smoked routes of administration that rapidly deliver the drug to the brain. Injecting is the use of a needle to administer the drug directly into the bloodstream. Snorting is the process of inhaling heroin powder through the nose, where it is absorbed into the bloodstream through the nasal tissues. Smoking involves inhaling heroin smoke into the lungs. All three methods of administering heroin can lead to addiction and other severe health problems. How Does Heroin Affect the Brain? Heroin enters the brain, where it is converted to morphine and binds to receptors known as opioid receptors. These receptors are located in many areas of the brain (and in the body), especially those involved in the perception of pain and in reward. Opioid receptors are also located in the brain stem important for automatic processes critical for life, such as breathing (respiration), blood pressure, and arousal. Heroin overdoses frequently involve a suppression of respiration. After an intravenous injection of heroin, users report feeling a surge of euphoria ( rush ) accompanied by dry mouth, a warm flushing of the skin, heaviness of the extremities, and clouded mental functioning. Following this initial euphoria, the user goes on the nod, an alternately wakeful and drowsy state. Users who do not inject the drug may not experience the initial rush, but other effects are the same. With regular heroin use, tolerance develops, in which the user s physiological (and psychological) response to the drug decreases, and more heroin is needed to achieve the same intensity of effect. Heroin users are at high risk for addiction it is estimated that about 23 percent of individuals who use heroin become dependent on it. What Other Adverse Effects Does Heroin Have on Health? Heroin abuse is associated with serious health conditions, including fatal overdose, spontaneous abortion, and particularly Updated March 2010 Page 1 of 5

13 in users who inject the drug infectious diseases, including HIV/AIDS and hepatitis. Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, and liver or kidney disease. Pulmonary complications, including various types of pneumonia, may result from the poor health of the abuser as well as from heroin s depressing effects on respiration. In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs. Chronic use of heroin leads to physical dependence, a state in which the body has adapted to the presence of the drug. If a dependent user reduces or stops use of the drug abruptly, he or she may experience severe symptoms of withdrawal. These symptoms which can begin as early as a few hours after the last drug administration can include restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps ( cold turkey ), and kicking movements ( kicking the habit ). Users also experience severe craving for the drug during withdrawal, which can precipitate continued abuse and/or relapse. Major withdrawal symptoms peak between 48 and 72 hours after the last dose of the drug and typically subside after about 1 week. Some individuals, however, may show persistent withdrawal symptoms for months. Although heroin withdrawal is considered less dangerous than alcohol or barbiturate withdrawal, sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal. In addition, heroin craving can persist years after drug cessation, particularly upon exposure to triggers such as stress or people, places, and things associated with drug use. Heroin abuse during pregnancy, together with related factors like poor nutrition and inadequate prenatal care, has been associated with adverse consequences including low birthweight, an important risk factor for later developmental delay. If the mother is regularly abusing the drug, the infant may be born physically dependent on heroin and could suffer from serious medical complications requiring hospitalization. What Treatment Options Exist? A range of treatments exist for heroin addiction, including medications and behavioral therapies. Science has taught us that when medication treatment is combined with other supportive services, patients are often able to stop using heroin (or other opiates) and return to stable and productive lives. Updated March 2010 Page 2 of 5

14 Treatment usually begins with medically assisted detoxification to help patients withdraw from the drug safely. Medications such as clonidine and buprenorphine can be used to help minimize symptoms of withdrawal. However, detoxification alone is not treatment and has not been shown to be effective in preventing relapse it is merely the first step. Medications to help prevent relapse include the following: Methadone has been used for more than 30 years to treat heroin addiction. It is a synthetic opiate medication that binds to the same receptors as heroin; but when taken orally, it has a gradual onset of action and sustained effects, reducing the desire for other opioid drugs while preventing withdrawal symptoms. Properly administered, methadone is not intoxicating or sedating, and its effects do not interfere with ordinary daily activities. Methadone maintenance treatment is usually conducted in specialized opiate treatment programs. The most effective methadone maintenance programs include individual and/or group counseling, as well as provision of or referral to other needed medical, psychological, and social services. Buprenorphine is a more recently approved treatment for heroin addiction (and other opiates). Compared with methadone, buprenorphine produces less risk for overdose and withdrawal effects and produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than those who stop taking methadone. The development of buprenorphine and its authorized use in physicians offices give opiate-addicted patients more medical options and extend the reach of addiction medication. Its accessibility may even prompt attempts to obtain treatment earlier. However, not all patients respond to buprenorphine some continue to require treatment with methadone. Naltrexone is approved for treating heroin addiction but has not been widely utilized due to poor patient compliance. This medication blocks opioids from binding to their receptors and thus prevents an addicted individual from feeling the effects of the drug. Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although initiation of the treatment often begins after medical detoxification in a residential setting. To prevent withdrawal symptoms, individuals Updated March 2010 Page 3 of 5

15 must be medically detoxified and opioidfree for several days before taking naltrexone. Naloxone is a shorter-acting opioid receptor blocker, used to treat cases of overdose. For pregnant heroin abusers, methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental maternal and neonatal outcomes associated with untreated heroin abuse. Preliminary evidence suggests that buprenorphine may also be a safe and effective treatment during pregnancy, although infants exposed to either methadone or buprenorphine prenatally may still require treatment for withdrawal symptoms. For women who do not want or are not able to receive pharmacotherapy for their heroin addiction, detoxification from opiates during pregnancy can be accomplished with medical supervision, although potential risks to the fetus and the likelihood of relapse to heroin use should be considered. There are many effective behavioral treatments available for heroin addiction usually in combination with medication. These can be delivered in residential or outpatient settings. Examples are individual or group counseling; contingency management, which uses a voucher-based system where patients earn points based on negative drug tests these points can be exchanged for items that encourage healthy living; and cognitive-behavioral therapy, designed to help modify a patient s expectations and behaviors related to drug abuse, and to increase skills in coping with various life stressors. How Widespread Is Heroin Abuse? Monitoring the Future Survey According to the Monitoring the Future survey, there was little change between 2008 and 2009 in the proportion of 8th- and 12th-grade students reporting lifetime, past-year, and past-month use of heroin. There also were no significant changes in past-year and past-month use among 10thgraders; however, lifetime use increased significantly among this age group, from 1.2 percent to 1.5 percent. Survey measures indicate that injection use rose significantly among this population at the same time. Use of Heroin by Students 2009 Monitoring the Future Survey 8th Grade 10th Grade 12th Grade Lifetime 1.3% 1.5% 1.2% Past Year 0.7% 0.9% 0.7% Past Month 0.4% 0.4% 0.4% Updated March 2010 Page 4 of 5

16 National Survey on Drug Use and Health (NSDUH) According to the 2008 National Survey on Drug Use and Health, the number of current (past-month) heroin users aged 12 or older in the United States increased from 153,000 in 2007 to 213,000 in There were 114,000 first-time users of heroin aged 12 or older in Other Information Sources For additional information on heroin, please refer to the following links on NIDA s Web site, Heroin Abuse Research Report Series Various issues of NIDA Notes (search by heroin or opiates ) For street terms searchable by drug name, cost and quantities, drug trade, and drug use, visit gov/streetterms/default.asp. Data Sources These data are from the 2009 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan s Institute for Social Research. The survey has tracked 12th-graders illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are on line at Lifetime refers to use at least once during a respondent s lifetime. Past year refers to use at least once during the year preceding an individual s response to the survey. Past month refers to use at least once during the 30 days preceding an individual s response to the survey. NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans aged 12 and older conducted by the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. This survey is available on line at and can be ordered by phone from NIDA at Updated March 2010 Page 5 of 5

17 MDMA ( Ecstasy ) MDMA (3,4- methylenedioxy- methamphetamine), popularly known as ecstasy, is a synthetic, psychoactive drug that has similarities to both the stimu- lant amphetamine and the hallucinogen mescaline. It produces feelings of in- creased energy, euphoria, emotional warmth and empathy toward others, and distortions in sensory and time percep- tion. MDMA was initially popular among White adolescents and young adults in the nightclub scene or at raves (long dance parties), but the drug now affects a broader range of users and ethnicities. How Is MDMA Abused? MDMA is taken orally, usually as a capsule or tablet. Its effects last approximately 3 to 6 hours, although it is not uncommon for users to take a second dose of the drug as the effects of the first dose begin to fade. It is commonly taken in combination with other drugs. For example some urban gay and bisexual men report using MDMA as part of a multiple-drug experience that includes cocaine, GHB, methamphetamine, ketamine, and the erectile-dysfunction drug sildenafil (Viagra). How Does MDMA Affect the Brain? MDMA acts by increasing the activity of three neurotransmitters, serotonin, do- pamine, and norepinephrine. The emo- tional and pro- social effects of MDMA are likely caused directly or indirectly by the release of large amounts of seroto- nin, which influences mood (as well as other functions such as appetite and sleep). Serotonin also triggers the re- lease of the hormones oxytocin and vas- opressin, which play important roles in Is MDMA Addictive? Research thus far on MDMA s addic- tive properties has shown varying re- sults, but we do know that some us- ers report symptoms of dependence, including continued use despite knowledge of physical or psychologi- cal harm, tolerance (or diminished response), and withdrawal effects. The neurotransmitter systems target- ed by MDMA are the same as those targeted by other addictive drugs. Ex- periments have shown that animals will self- administer MDMA an im- portant indicator of a drug s abuse potential although the degree of self- administration is less than some other drugs of abuse such as cocaine. MDMA ( Ecstasy ) December 2012 Page 1

18 love, trust, sexual arousal, and other so- cial experiences. This may account for the characteristic feelings of emotional closeness and empathy produced by the drug; studies in both rats and humans have shown that MDMA raises the levels of these hormones. The surge of serotonin caused by taking MDMA depletes the brain of this im- portant chemical, however, causing neg- ative aftereffects including confusion, depression, sleep problems, drug crav- ing, and anxiety that may occur soon after taking the drug or during the days or even weeks thereafter. Some heavy MDMA users experience long- lasting confusion, depression, sleep abnormalities, and problems with atten- tion and memory, although it is possible that some of these effects may be due to the use of other drugs in combination with MDMA (especially marijuana). What Are the Other Health Effects of MDMA? MDMA can have many of the same phys- ical effects as other stimulants like co- caine and amphetamines. These include increases in heart rate and blood pres- sure, which are particularly risky for people with circulatory problems or heart disease. MDMA users may experi- ence other symptoms such as muscle tension, involuntary teeth clenching, nausea, blurred vision, faintness, and chills or sweating. In high doses, MDMA can interfere with the body s ability to regulate tempera- ture. On rare but unpredictable occa- sions, this can lead to a sharp increase in body temperature (hyperthermia), which can result in liver, kidney, or car- diovascular system failure or even death. MDMA can interfere with its own me- tabolism (breakdown within the body), causing potentially harmful levels to build up in the body if it is taken repeat- edly within short periods of time. Compounding the risks of ecstasy use is the fact that other potentially harmful drugs (including synthetic cathinones, the psychoactive ingredients in bath salts ) are sometimes sold as ecstasy. These drugs can be neurotoxic or pose other unpredictable health risks. And ec- stasy tablets that do contain MDMA may contain additional substances such as ephedrine (a stimulant), dextrome- thorphan (a cough suppressant), keta- mine, caffeine, cocaine, or methamphet- amine. The combination of MDMA with one or more of these drugs may be haz- ardous. Users who intentionally or un- knowingly combine such a mixture with additional substances such as marijuana and alcohol may be putting themselves at even higher risk for adverse health ef- fects. Additionally, the closeness- promoting ef- fects of MDMA and its use in sexually charged contexts (and especially in com- Does MDMA Have Therapeu- tic Value? MDMA was first used in the 1970s, not as a recreational drug but as an aid in psychotherapy although without the support of clinical trial research or FDA approval. In 1985, the Drug Enforcement Administra- tion labeled MDMA a Schedule I substance, or a drug with high abuse potential and no recognized medicinal use. Some researchers remain interested in its potential therapeutic value when adminis- tered under carefully monitored conditions. It is currently in clinical trials as a possible pharmacothera- py aid to treat post- traumatic stress disorder (PTSD) and anxiety in ter- minal cancer patients. MDMA ( Ecstasy ) December 2012 Page 2

19 bination with sildenafil) may encourage unsafe sex, which is a risk factor for con- tracting or spreading HIV and hepatitis. Learn More For additional information on MDMA, please see s/research- reports/mdma- ecstasy- abuse MDMA ( Ecstasy ) December 2012 Page 3

20 Methamphetamine Methamphetamine is a central nervous system stimulant drug that is similar in structure to amphetamine. Due to its high potential for abuse, methamphetamine is classified as a Schedule II drug and is available only through a prescription that cannot be refilled. Although methamphetamine can be prescribed by a doctor, its medical uses are limited, and the doses that are prescribed are much lower than those typically abused. Most of the methamphetamine abused in this country comes from foreign or domestic superlabs, although it can also be made in small, illegal laboratories, where its production endangers the people in the labs, neighbors, and the environment. How Is Methamphetamine Abused? Methamphetamine is a white, odorless, bitter-tasting crystalline powder that easily dissolves in water or alcohol and is taken orally, intranasally (snorting the powder), by needle injection, or by smoking. How Does Methamphetamine Affect the Brain? Methamphetamine increases the release and blocks the reuptake of the brain chemical (or neurotransmitter) dopamine, leading to high levels of the chemical in the brain a common mechanism of action for most drugs of abuse. Dopamine is involved in reward, motivation, the experience of pleasure, and motor function. Methamphetamine s ability to release dopamine rapidly in reward regions of the brain produces the intense euphoria, or rush, that many users feel after snorting, smoking, or injecting the drug. Chronic methamphetamine abuse significantly changes how the brain functions. Noninvasive human brain imaging studies have shown alterations in the activity of the dopamine system that are associated with reduced motor skills and impaired verbal learning. 1 Recent studies in chronic methamphetamine abusers have also revealed severe structural and functional changes in areas of the brain associated with emotion and memory, 2,3 which may account for many of the emotional and cognitive problems observed in chronic methamphetamine abusers. Updated March 2010 Page 1 of 4

21 Repeated methamphetamine abuse can also lead to addiction a chronic, relapsing disease characterized by compulsive drug seeking and use, which is accompanied by chemical and molecular changes in the brain. Some of these changes persist long after methamphetamine abuse is stopped. Reversal of some of the changes, however, may be observed after sustained periods of abstinence (e.g., more than 1 year). 4 What Other Adverse Effects Does Methamphetamine Have on Health? Taking even small amounts of methamphetamine can result in many of the same physical effects as those of other stimulants, such as cocaine or amphetamines, including increased wakefulness, increased physical activity, decreased appetite, increased respiration, rapid heart rate, irregular heartbeat, increased blood pressure, and hyperthermia. Long-term methamphetamine abuse has many negative health consequences, including extreme weight loss, severe dental problems ( meth mouth ), anxiety, confusion, insomnia, mood disturbances, and violent behavior. Chronic methamphetamine abusers can also display a number of psychotic features, including paranoia, visual and auditory hallucinations, and delusions (for example, the sensation of insects crawling under the skin). Transmission of HIV and hepatitis B and C can be consequences of methamphetamine abuse. The intoxicating effects of methamphetamine, regardless of how it is taken, can also alter judgment and inhibition and can lead people to engage in unsafe behaviors, including risky sexual behavior. Among abusers who inject the drug, HIV/ AIDS and other infectious diseases can be spread through contaminated needles, syringes, and other injection equipment that is used by more than one person. Methamphetamine abuse may also worsen the progression of HIV/AIDS and its consequences. Studies of methamphetamine abusers who are HIV-positive indicate that HIV causes greater neuronal injury and cognitive impairment for individuals in this group compared with HIV-positive people who do not use the drug. 5,6 What Treatment Options Exist? Currently, the most effective treatments for methamphetamine addiction are comprehensive cognitive-behavioral interventions. For example, the Matrix Updated March 2010 Page 2 of 4

22 Model a behavioral treatment approach that combines behavioral therapy, family education, individual counseling, 12-step support, drug testing, and encouragement for nondrug-related activities has been shown to be effective in reducing methamphetamine abuse. 7 Contingency management interventions, which provide tangible incentives in exchange for engaging in treatment and maintaining abstinence, have also been shown to be effective. 8 There are no medications at this time approved to treat methamphetamine addiction; however, this is an active area of research for NIDA. How Widespread Is Methamphetamine Abuse? Monitoring the Future Survey Methamphetamine use among teens appears to have dropped significantly in recent years, according to data revealed by the 2009 Monitoring the Future survey. The number of high-school seniors reporting past-year use is now only at 1.2 percent, which is the lowest since questions about methamphetamine were added to the survey in 1999; at that time, it was reported at 4.7 percent. Lifetime use among 8th-graders was reported at 1.6 percent in 2009, down significantly from 2.3 percent in In addition, the proportion of 10th-graders reporting that crystal methamphetamine was easy to obtain has dropped to 14 percent, down from 19.5 percent 5 years ago. Use of Methamphetamine by Students 2009 Monitoring the Future Survey 8th Grade 10th Grade 12th Grade Lifetime 1.6% 2.8% 2.4% Past Year 1.0% 1.6% 1.2% Past Month 0.5% 0.6% 0.5% National Survey on Drug Use and Health (NSDUH) According to the 2008 National Survey on Drug Use and Health, the number of pastmonth methamphetamine users age 12 and older decreased by over half between 2006 and Current (past-month) users were numbered at 731,000 in 2006, 529,000 in 2007, and 314,000 in Significant declines from 2002 and 2008 also were noted for lifetime and past-year use in this age group. From 2002 to 2008, past-month use of methamphetamine declined significantly among youths aged 12 to 17, from 0.3 percent to 0.1 percent, and young adults aged 18 to 25 also reported significant declines in past-month use, from 0.6 percent in 2002 to 0.2 percent in Updated March 2010 Page 3 of 4

23 Other Information Sources For more information on the effects of methamphetamine abuse and addiction, visit drugpages/methamphetamine.html. For street terms searchable by drug name, cost and quantities, drug trade, and drug use, visit gov/streetterms/default.asp. To find publicly funded treatment facilities by state, visit samhsa.gov. Data Sources These data are from the 2009 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan s Institute for Social Research. The survey has tracked 12th-graders illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. Questions about crystal methamphetamine were added to the 12th-grade and followup surveys in 1990, and questions about methamphetamine were added to the study for all three grades in The latest data are on line at Lifetime refers to use at least once during a respondent s lifetime. Past year refers to use at least once during the year preceding an individual s response to the survey. Past month refers to use at least once during the 30 days preceding an individual s response to the survey. NSDUH (formerly known as the National Household Survey on Drug Abuse) is an annual survey of Americans aged 12 and older conducted by the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. This survey is available on line at and can be ordered by phone from NIDA at References 1 Volkow ND, Chang L, Wang GJ, et al. Association of dopamine transporter reduction with psychomotor impairment in methamphetamine abusers. Am J Psychiatry 158(3): , London ED, Simon SL, Berman SM, et al. Mood disturbances and regional cerebral metabolic abnormalities in recently abstinent methamphetamine abusers. Arch Gen Psychiatry 61(1):73 84, Thompson PM, Hayashi KM, Simon SL, et al. Structural abnormalities in the brains of human subjects who use methamphetamine. J Neurosci 24(26): , Wang GJ, Volkow ND, Chang L, et al. Partial recovery of brain metabolism in methamphetamine abusers after protracted abstinence. Am J Psychiatry 161(2): , Chang L, Ernst T, Speck O, Grob CS. Additive effects of HIV and chronic methamphetamine use on brain metabolite abnormalities. Am J Psychiatry 162(2): , Rippeth JD, Heaton RK, Carey CL, et al. Methamphetamine dependence increases risk of neuropsychological impairment in HIV infected persons. J Int Neuropsychol Soc 10(1):1 14, Rawson RA, Marinelli-Casey P, Anglin MD, et al. A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction 99(6): , Roll JM, Petry NM, Stitzer ML, et al. Contingency management for the treatment of methamphetamine use disorders. Am J Psychiatry 163(11): , Updated March 2010 Page 4 of 4

24 Prescription and Over- the- Counter Medications Some medications have psychoactive (mind- altering) properties and, because of that, are sometimes abused that is, taken for reasons or in ways or amounts not intended by a doctor, or taken by someone other than the person for whom they are prescribed. In fact, pre- scription and over- the- counter (OTC) drugs are, after marijuana (and alcohol), the most commonly abused substances by Americans 14 and older. Past- Year Use of Illicit Drugs and Pharmaceu8cals among 12th Graders Marijuana/Hashish SyntheFc Marijuana Adderall Vicodin Cough Medicine Tranquilizers Hallucinogens SedaFves Salvia OxyConFn MDMA (Ecstasy) Inhalants Cocaine (any form) Ritalin 5.3% 4.8% 4.5% 4.4% 4.3% 3.8% 2.9% 2.7% 2.6% 7.6% 7.5% 5.6% 11.3% 36.4% Illicit Drugs PharmaceuFcal SOURCE: University of Michigan, 2012 Monitoring the Future Study The classes of prescription drugs most commonly abused are: opioid pain re- lievers, such as Vicodin or Oxycontin; stimulants for treating Attention Deficit Hyperactivity Disorder (ADHD), such as Adderall, Concerta, or Ritalin; and cen- tral nervous system (CNS) depressants for relieving anxiety, such as Valium or Xanax. 1 The most commonly abused OTC drugs are cough and cold remedies con- taining dextromethorphan. People often think that prescription and OTC drugs are safer than illicit drugs, but that s only true when they are taken ex- actly as prescribed and for the purpose intended. When abused, prescription and OTC drugs can be addictive and put abusers at risk for other adverse health effects, including overdose especially when taken along with other drugs or al- cohol. How Are Prescription Drugs Abused? Prescription and OTC drugs may be abused in one or more of the following ways: Taking a medication that has been pre- scribed for somebody else. Unaware of the dangers of sharing medications, people often unknowingly contribute to this 1 These are proprietary names of particular drug products. Generic versions may also exist. Prescription and Over-the-Counter Medications December 2012 Page 1

25 form of abuse by sharing their unused pain relievers with their family mem- Most teenagers who abuse pre- scription drugs are given them for free by a friend or relative. bers. Taking a drug in a higher quantity or in another manner than prescribed. Most prescription drugs are dispensed orally in tablets, but abusers sometimes crush the tablets and snort or inject the pow- der. This hastens the entry of the drug into the bloodstream and the brain and amplifies its effects. Taking a drug for another purpose than prescribed. All of the drug types men- tioned can produce pleasurable effects at sufficient quantities, so taking them for the purpose of getting high is one of the main reasons people abuse them. ADHD drugs like Adderall are also often abused by students for their effects in promoting alertness and concentration. How Do Prescription and OTC Drugs Affect the Brain? Taken as intended, prescription and OTC drugs safely treat specific mental or physical symptoms. But when taken in different quantities or when such symp- toms aren t present, they may affect the brain in ways very similar to illicit drugs. For example, stimulants such as Ritalin increase alertness, attention, and energy the same way cocaine does by boosting the amount of the neurotransmitter dopamine. Opioid pain relievers like Ox- ycontin attach to the same cell receptors targeted by illegal opioids like heroin. Prescription depressants produce sedat- ing or calming effects in the same man- ner as the club drugs GHB and rohypnol, by enhancing the actions of the neuro- transmitter GABA (gamma- aminobutyric acid). When taken in very high doses, dextromethorphan acts on the same glu- tamate receptors as PCP or ketamine, producing similar out- of- body experi- ences. When abused, all of these classes of drugs directly or indirectly cause a pleasurable increase in the amount of dopamine in the brain s reward path- way. Repeatedly seeking to experience that feeling can lead to addiction. What Are the Other Health Effects of Prescription and OTC Drugs? Stimulants can have strong effects on the cardiovascular system. Taking high dos- es of a stimulant can dangerously raise body temperature and cause irregular heartbeat or even heart failure or sei- zures. Also, taking some stimulants in high doses or repeatedly can lead to hos- tility or feelings of paranoia. Opioids can produce drowsiness, cause constipation, and depending upon the amount taken depress breathing. The latter effect makes opioids particularly dangerous, especially when they are snorted or injected or combined with other drugs or alcohol. CNS depressants slow down brain activi- ty and can cause sleepiness and loss of coordination. Continued use can lead to physical dependence and withdrawal symptoms if discontinuing use. Prescription and Over-the-Counter Medications December 2012 Page 2

26 Dextromethorphan can cause impaired motor function, numbness, nausea or vomiting, and increased heart rate and blood pressure. On rare occasions, hy- poxic brain damage caused by severe respiratory depression and a lack of oxy- gen to the brain has occurred due to the combination of dextromethorphan with decongestants often found in the medication. Deaths per 100,000 popula8on Deaths from Opioid Pain Relievers Exceed Those from All Illegal Drugs Opioid pain relievers Illegal drugs Age Group All of these drugs have the potential for addiction, and this risk is amplified when they are abused. Also, as with other drugs, abuse of prescription and OTC drugs can alter a person s judgment and decisionmaking, leading to dangerous behaviors such as unsafe sex and drugged driving. Learn More For more information on prescription and OTC drugs, visit s/research- reports/prescription- drugs Source: CDC, Morbidity and Mortality Weekly Report, 60(43): 1489, Prescription and Over-the-Counter Medications December 2012 Page 3

27 Salvia Salvia (Salvia divinorum) is an herb common to southern Mexico and Central and South America. The main active ingredient in Salvia, salvinorin A, is a potent activator of kappa opioid receptors in the brain. 1,2 These receptors differ from those activated by the more commonly known opioids, such as heroin and morphine. Traditionally, S. divinorum has been ingested by chewing fresh leaves or by drinking their extracted juices. The dried leaves of S. divinorum can also be smoked as a joint, consumed in water pipes, or vaporized and inhaled. Although Salvia currently is not a drug regulated by the Controlled Substances Act, several States and countries have passed legislation to regulate its use. 3 The Drug Enforcement Agency has listed Salvia as a drug of concern and is considering classifying it as a Schedule I drug, like LSD or marijuana. Health/Behavioral Effects People who abuse salvia generally experience hallucinations or psychotomimetic episodes (a transient experience that mimics a psychosis). 4,5 Subjective effects have been described as intense but short-lived, appearing in less than 1 minute and lasting less than 30 minutes. They include psychedelic-like changes in visual perception, mood and body sensations, emotional swings, feelings of detachment, and importantly, a highly modified perception of external reality and the self, leading to a decreased ability to interact with one's surroundings. 5 This last effect has prompted concern about the dangers of driving under the influence of salvinorin. The long-term effects of Salvia abuse have not been investigated systematically. Recent experiments in rodents demonstrated deleterious effects of salvinorin A on learning and memory. 6 Extent of Use NIDA s Monitoring the Future Survey of 8 th, 10 th, and 12 th graders asked about salvia abuse for the first time in percent of high school seniors reported past year use (greater than the percent reporting ecstasy use). And according to the latest MTF figures the use of Salvia reported by 8 th graders remained unchanged from 2011 to 2012 at 1.4 percent. Among 10 th and 12 th graders there was a decline 2.5 percent of 10 th graders and 4.4 percent of 12 th graders reported past year abuse.

28 Although information about this drug is limited, its abuse is likely driven by drugrelated videos and information on Internet sites. 3 Because of the nature of the drug s effects its use may be restricted to individual experimentalists, rather than as a social or party drug 5 Learn More For more information on the effects of hallucinogenic drugs, see NIDA s Research Report on Hallucinogens and Dissociative Drugs at ogens/hallucinogens.html. For more information on Salvia divinorum and the Controlled Substances Act, visit oncern/salvia_d.pdf. Complete MTF survey results are available at For more information on the survey and its findings, also visit topics/trends- statistics/monitoring- future. Citations 1 Chavkin, C., Sud, S., Jin, W. et al. Salvinorin A, an active component of the hallucinogenic sage Salvia divinorum is a highly efficacious kappa- opioid receptor agonist: structural and functional considerations. J Pharmacol Exp Ther. 308: , Roth, B.L., et al. Salvinorin A: a potent naturally occurring non- nitrogenous kappa opioid selective agonist. Proc Natl Acad Sci. 99: , Gonzalez, D., et al. Pattern of use and subjective effects of Salvia divinorum among recreational users. Drug Alcohol Depend. 85: , Braida D, Donzelli A, Martucci R, Capurro V, Sala M. Learning and memory impairment induced by salvinorin A, the principal ingredient of Salvia divinorum, in wistar rats. Int J Toxicol Dec;30(6): About the Survey Since 1975, the MTF survey has measured drug, alcohol, and cigarette use and related attitudes among 12th graders, nationwide. In 1991, 8th and 10th graders were added to the survey. Survey participants report their drug use behaviors across three time periods: lifetime, past year, and past month. Overall, 44,449 students from 395 public and private schools in the 8th, 10th, and 12th grades participated in the 2012 survey. The survey is funded by NIDA and conducted by the University of Michigan. Results from the survey are released each December. 2 Harding, W.W., et al. Salvinicins A and B, new neoclerodane diterpenes from Salvia divinorum. Organic Letters. 7: , ern/salvia_d.pdf. Accessed September 24, 2007.

29 Spice (Synthetic Marijuana) Spice refers to a wide variety of herbal mixtures that produce experiences simi- lar to marijuana (cannabis) and that are marketed as safe, legal alternatives to that drug. Sold under many names, in- cluding K2, fake weed, Yucatan Fire, Skunk, Moon Rocks, and others and la- beled not for human consumption these products contain dried, shredded plant material and chemical additives that are responsible for their psychoac- tive (mind- altering) effects. False Advertising Labels on Spice products often claim that they contain natural psycho- active material taken from a variety of plants. Spice products do contain dried plant material, but chemical analyses show that their active in- gredients are synthetic (or designer) cannabinoid compounds. For several years, Spice mixtures have been easy to purchase in head shops and gas stations and via the Internet. Be- cause the chemicals used in Spice have a high potential for abuse and no medical benefit, the Drug Enforcement Admin- istration (DEA) has designated the five active chemicals most frequently found in Spice as Schedule I controlled substances, making it illegal to sell, buy, or possess them. Manufacturers of Spice products attempt to evade these legal re- strictions by substituting different chem- icals in their mixtures, while the DEA continues to monitor the situation and evaluate the need for updating the list of banned cannabinoids. Spice products are popular among young people; of the illicit drugs most used by high- school seniors, they are second only to marijuana. (They are more popular among boys than girls in 2012, nearly twice as many male 12 th graders report- ed past- year use of synthetic marijuana as females in the same age group.) Easy access and the misperception that Spice products are natural and therefore harmless have likely contributed to their popularity. Another selling point is that the chemicals used in Spice are not easily detected in standard drug tests. Past- Year Use of Illicit Drugs by High School Seniors (percent) Marijuana/Hashish SyntheBc Marijuana Hallucinogens Salvia MDMA (Ecstasy) Cocaine SOURCE: University of Michigan, 2012 Monitoring the Future Study Spice (Synthetic Marijuana) December 2012 Page 1

30 How Is Spice Abused? Some Spice products are sold as in- cense, but they more closely resemble potpourri. Like marijuana, Spice is abused mainly by smoking. Sometimes Spice is mixed with marijuana or is pre- pared as an herbal infusion for drinking. Spice, however, bind more strongly to those receptors, which could lead to a much more powerful and unpredictable effect. Because the chemical composition of many products sold as Spice is un- known, it is likely that some varieties al- so contain substances that could cause dramatically different effects than the user might expect. What Are the Other Health Effects of Spice? K2, a popular brand of Spice mixture. How Does Spice Affect the Brain? Spice users report experiences similar to those produced by marijuana elevated mood, relaxation, and altered percep- tion and in some cases the effects are even stronger than those of marijuana. Some users report psychotic effects like extreme anxiety, paranoia, and hallucina- tions. So far, there have been no scientific stud- ies of Spice s effects on the human brain, but we do know that the cannabinoid compounds found in Spice products act on the same cell receptors as THC, the primary psychoactive component of ma- rijuana. Some of the compounds found in Spice abusers who have been taken to Poison Control Centers report symptoms that include rapid heart rate, vomiting, agitation, confusion, and hallucinations. Spice can also raise blood pressure and cause reduced blood supply to the heart (myocardial ischemia), and in a few cas- es it has been associated with heart at- tacks. Regular users may experience withdrawal and addiction symptoms. We still do not know all the ways Spice may affect human health or how toxic it may be, but one public health concern is that there may be harmful heavy metal residues in Spice mixtures. Without fur- ther analyses, it is difficult to determine whether this concern is justified. Learn More For additional information on Spice, see ments.cfm/att_80086_en_spice%20the matic%20paper%20 %20final%20version.pdf Spice (Synthetic Marijuana) December 2012 Page 2

31 Inhalants Many products readily found in the home or workplace such as spray paints, markers, glues, and cleaning fluids contain volatile substances that have psychoactive (mind- altering) properties when inhaled. People do not typically think of these products as drugs because they were never intended for that purpose. However, these products are some- times abused in that way. They are especially (but not exclusively) abused by young children and adoles- cents, and are the only class of sub- stance abused more by younger than by older teens. Grade High- School Students Repor:ng Having Ever Used Inhalants 8th 10th 12th Definition Although other abused drugs can be inhaled, the term inhalants is reserved for the wide variety of substances including solvents, aerosols, gases, and nitrites that are rarely, if ever, taken via any other route of administration. (See below for a list of examples.) may sniff or snort fumes from a con- tainer or dispenser (such as a glue bottle or a marking pen), spray aero- sols (such as computer cleaning dust- ers) directly into their nose or mouth, or place a chemical- soaked rag in their mouth. Abusers may also inhale fumes from a balloon or a plastic or paper bag. Although the high produced by inhalants usually lasts just a few minutes, abusers often try to prolong it by continuing to inhale repeatedly over several hours. 0.00% 5.00% 10.00% 15.00% Source: University of Michigan, 2011 Monitoring the Future Study. Survey data can be found at How Are Inhalants Abused? Abusers of inhalants breathe them in through the nose or mouth in a varie- ty of ways (known as huffing ). They Inhalants September 2012 Page 1 People tend to abuse different inhal- ant products at different ages. New users ages most commonly abuse glue, shoe polish, spray paints, gasoline, and lighter fluid. New users ages most commonly abuse ni- trous oxide or whippets. Adults most commonly abuse a class of in- halants known as nitrites (such as amyl nitrites or poppers ).

32 How Do Inhalants Affect the Brain? Most abused inhalants other than ni- trites depress the central nervous sys- tem in a manner not unlike alcohol. The effects are similar including slurred speech, lack of coordination, euphoria, and dizziness. Inhalant abusers may also experience light- headedness, hallucinations, and delu- sions. With repeated inhalations, many users feel less inhibited and less in control. Some may feel drowsy for several hours and experience a linger- ing headache. Products Abused as Inhalants Volatile solvents liquids that vaporize at room temperature: Industrial or household products, including paint thinners or removers, degreasers, dry- cleaning fluids, gasoline, and lighter fluid Art or office supply solvents, including correc- tion fluids, felt- tip marker fluid, electronic con- tact cleaners, and glue Aerosols sprays that contain propellants and solvents: Household aerosol propellants in items such as spray paints, hair or deodorant sprays, fabric protector sprays, aerosol computer cleaning products, and vegetable oil sprays Unlike other types of inhalants, nitrites enhance sexual pleasure by dilating and relaxing blood vessels. Although it is not very common, ad- diction to inhalants can occur with re- peated abuse. What Are the Other Health Effects of Inhalants? Chemicals found in different types of inhaled products may produce a vari- ety of other short- term effects, such as nausea or vomiting, as well as more serious long- term consequences. The- se may include liver and kidney dam- age, hearing loss, or bone marrow damage. Effects may also include loss of coordination and limb spasms due to damage to myelin a protective sheathing around nerve fibers that helps nerves transmit messages in the brain and peripheral nervous system. Inhalants can also cause brain damage by cutting off oxygen flow to the brain. Inhalants can even be lethal. Sniffing highly concentrated amounts of the chemicals in solvents or aerosol sprays can directly cause heart failure within minutes. This syndrome, known as sudden sniffing death, can result from a single session of inhalant use by an otherwise healthy young Inhalants September 2012 Page 2 Gases found in household or commercial prod- ucts and used as medical anesthetics: Household or commercial products, including butane lighters and propane tanks, whipped cream aerosols or dispensers ( whippets ), and refrigerant gases Medical anesthetics, such as ether, chloro- form, halothane, and nitrous oxide ( laughing gas ) Nitrites used primarily as sexual enhancers: Organic nitrites are volatiles that include cy- clohexyl, butyl, and amyl nitrites, commonly known as poppers. Amyl nitrite is still used in certain diagnostic medical procedures. When marketed for illicit use, organic nitrites are of- ten sold in small brown bottles labeled as vid- eo head cleaner, room odorizer, leather cleaner, or liquid aroma. person. High concentrations of inhal- ants may also cause death from suffo- cation, especially when inhaled from a paper or plastic bag or in a closed ar- ea. Even when using aerosols or vola- tile products for their legitimate pur- poses like painting or cleaning, it is wise to do so in a well- ventilated room or outdoors. Nitrites are a special class of inhalants that are abused to enhance sexual pleasure and performance. They can be associated with unsafe sexual prac- tices that increase the risk of contract- ing and spreading infectious diseases like HIV/AIDS and hepatitis.

33 Learn More For additional information on inhal- ants and inhalant abuse, please see ons/research- reports/inhalant- abuse Inhalants September 2012 Page 3

34 Club Drugs (GHB, Ketamine, and Rohypnol) Club drugs are a pharmacologically heterogeneous group of psychoactive drugs that tend to be abused by teens and young adults at bars, nightclubs, concerts, and parties. Gamma hydroxybutyrate (GHB), Rohypnol, ketamine, as well as MDMA (ecstasy) and methamphetamine (which are featured in separate InfoFacts) are some of the drugs included in this group. GHB (Xyrem) is a central nervous system (CNS) depressant that was approved by the Food and Drug Administration (FDA) in 2002 for use in the treatment of narcolepsy (a sleep disorder). This approval came with severe restrictions, including its use only for the treatment of narcolepsy, and the requirement for a patient registry monitored by the FDA. GHB is also a metabolite of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). It exists naturally in the brain, but at much lower concentrations than those found when GHB is abused. Rohypnol (flunitrazepam) use began gaining popularity in the United States in the early 1990s. It is a benzodiazepine (chemically similar to sedative-hypnotic drugs such as Valium or Xanax), but it is not approved for medical use in this country, and its importation is banned. Ketamine is a dissociative anesthetic, mostly used in veterinary practice. How Are Club Drugs Abused? GHB and Rohypnol are available in odorless, colorless, and tasteless forms that are frequently combined with alcohol and other beverages. Both drugs have been used to commit sexual assaults (also known as date rape, drug rape, acquaintance rape, or drug-assisted assault) due to their ability to sedate and incapacitate unsuspecting victims, preventing them from resisting sexual assault. GHB is usually ingested orally, either in liquid or powder form, while Rohypnol is typically taken orally in pill form. Recent reports, however, have shown that Rohypnol is being ground up and snorted. Both GHB and Rohypnol are also abused for their intoxicating effects, similar to other CNS depressants. GHB also has anabolic effects (it stimulates protein synthesis) and has been used by bodybuilders to aid in fat reduction and muscle building. Ketamine is usually snorted or injected intramuscularly. Updated July 2010 Page 1 of 4

35 How Do Club Drugs Affect the Brain? GHB acts on at least two sites in the brain: the GABA B receptor and a specific GHB binding site. At high doses, GHB s sedative effects may result in sleep, coma, or death. Rohypnol, like other benzodiazepines, acts at the GABAA receptor. It can produce anterograde amnesia, in which individuals may not remember events they experienced while under the influence of the drug. Ketamine is a dissociative anesthetic, so called because it distorts perceptions of sight and sound and produces feelings of detachment from the environment and self. Ketamine acts on a type of glutamate receptor (NMDA receptor) to produce its effects, which are similar to those of the drug PCP. 1,2, Low-dose intoxication results in impaired attention, learning ability, and memory. At higher doses, ketamine can cause dreamlike states and hallucinations; and at higher doses still, ketamine can cause delirium and amnesia. Addictive Potential Repeated use of GHB may lead to withdrawal effects, including insomnia, anxiety, tremors, and sweating. Severe withdrawal reactions have been reported among patients presenting from an overdose of GHB or related compounds, especially if other drugs or alcohol are involved. 3 Like other benzodiazepines, chronic use of Rohypnol can produce tolerance, physical dependence, and addiction. There have been reports of people binging on ketamine, a behavior that is similar to that seen in some cocaine- or amphetamine-dependent individuals. Ketamine users can develop signs of tolerance and cravings for the drug. 4 What Other Adverse Effects Do Club Drugs Have on Health? Uncertainties about the sources, chemicals, and possible contaminants used to manufacture many club drugs make it extremely difficult to determine toxicity and associated medical consequences. Nonetheless, we do know that: Coma and seizures can occur following use of GHB. Combined use with other drugs such as alcohol can result in nausea and breathing difficulties. GHB and two of its precursors, gamma butyrolactone (GBL) and 1,4 butanediol (BD), have been involved in poisonings, overdoses, date rapes, and deaths. Updated July 2010 Page 2 of 4

36 Rohypnol may be lethal when mixed with alcohol and/or other CNS depressants. Ketamine, in high doses, can cause impaired motor function, high blood pressure, and potentially fatal respiratory problems. What Treatment Options Exist? There is very little information available in the scientific literature about treatment for persons who abuse or are dependent upon club drugs. There are no GHB detection tests for use in emergency rooms, and as many clinicians are unfamiliar with the drug, many GHB incidents likely go undetected. According to case reports, however, patients who abuse GHB appear to present both a mixed picture of severe problems upon admission and a good response to treatment, which often involves residential services. 3 Treatment for Rohypnol follows accepted protocols for any benzodiazepine, which may consist of a 3- to 5-day inpatient detoxification program with 24-hour intensive medical monitoring and management of withdrawal symptoms, since withdrawal from benzodiazepines can be life-threatening. 3 Patients with a ketamine overdose are managed through supportive care for acute symptoms, with special attention to cardiac and respiratory functions. 5 How Widespread Is Club Drug Abuse? Monitoring the Future Survey MTF has reported consistently low levels of abuse of these club drugs since they were added to the survey. For GHB and ketamine, this occurred in 2000; for Rohypnol, According to results of the 2009 MTF survey, 0.7 percent of 8th-grade and 1.1 percent of 12th-grade students reported past-year use of GHB, a statistically significant decrease from peak-year use of 1.2 percent in 2000 for 8th-graders and 2.0 percent for 12th-graders in GHB use among 10th-grade students was reported at 1.0 percent, an increase from 2008 (0.5 percent), and statistically unchanged from peak use of 1.4 percent in 2002 and Past-year use of ketamine was reported by 1.0 percent of 8th-graders, 1.3 percent of 10th-graders, and 1.7 percent of 12thgraders in These percentages also represent significant decreases from peak years: 2000 for 8th-graders (at 1.6 percent) and 2002 for 10th- and 12th-graders (at 2.2 and 2.6 percent, respectively). Updated July 2010 Page 3 of 4

37 For Rohypnol, 0.4 percent of 8th- and 10th-graders, and 1.0 percent of 12thgraders reported past-year use, also down from peak use in 1996 for 8th-graders (1.0 percent), 1997 for 10th-graders (1.3 percent), and 2002 and 2004 for 12thgraders (1.6 percent). Other Information Sources For more information about club drugs, visit www. teens.drugabuse.gov, and www. backtoschool.drugabuse.gov; or call NIDA at For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit whitehousedrugpolicy.gov/ streetterms/default.asp. Data Sources These data are from the 2009 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan s Institute for Social Research. The survey has tracked 12th-graders illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. Lifetime refers to use at least once during a respondent s lifetime. Past year refers to use at least once during the year preceding an individual s response to the survey. Past month refers to use at least once during the 30 days preceding an individual s response to the survey. Resources 1 Anis NA, Berry SC, Burton NR, Lodge D. The dissociative anaesthetics, datamine and phencyclidine, selectively reduce excitation of central mammalian neurons by N-methyl-aspartate. Br J Pharmacol 79(2): , Kapur S, Seeman P. NMDA receptor antagonists ketamine and PCP have direct effects on dopamine D2 and serotonin 5-HT2 receptors Implications for models of schizophrenia. Molecular Psychiatry 7: , Maxwell JC, Spence RT. Profiles of club drug users in treatment. Subst Use Misuse 40(9 10): , Jansen KL, Darracot-Cankovic R. The nonmedical use of ketamine, part two: A review of problem use and dependence. J Psychoactive Drugs 33(2): , Smith KM, Larive LL, Romanelli F. Club Drugs: Methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and γ hydroxybutyrate. Am J Health-Syst Pharm 59(11): , Updated July 2010 Page 4 of 4

38 Marijuana is a dry, shredded green and brown mix of leaves, flowers, stems, and seeds from the hemp plant Cannabis sa- tiva. In a more concentrated, resinous form, it is called hashish, and as a sticky black liquid, hash oil. The main psycho- active (mind- altering) chemical in mari- juana is delta- 9- tetrahydrocannabinol, or THC. Marijuana Marijuana is the most common illicit drug used in the United States. After a period of decline in the last decade, its use has generally increased among young people since 2007, corresponding to a diminishing perception of the drug s risks. More teenagers are now current (past- month) smokers of marijuana than of cigarettes, according to annual survey data. How Is Marijuana Used? Marijuana is usually smoked in hand- rolled cigarettes (joints) or in pipes or water pipes (bongs). It is also smoked in blunts cigars that have been emptied of tobacco and refilled with a mixture of marijuana and tobacco. Marijuana smoke has a pungent and distinctive, usually sweet- and- sour, odor. Marijuana can al- so be mixed in food or brewed as a tea. How Does Marijuana Affect the Brain? When marijuana is smoked, THC rapidly passes from the lungs into the blood- stream, which carries the chemical to the brain and other organs throughout the body. It is absorbed more slowly when ingested in food or drink. However it is ingested, THC acts upon specific molecular targets on brain cells, called cannabinoid receptors. These re- ceptors are ordinarily activated by chem- icals similar to THC called endocanna- binoids, such as anandamide. These are naturally occurring in the body and are part of a neural communication network (the endocannabinoid system) that plays an important role in normal brain devel- opment and function. Marijuana December 2012 Page 1 The highest density of cannabinoid re- ceptors is found in parts of the brain that

39 influence pleasure, memory, thinking, concentration, sensory and time percep- tion, and coordinated movement. Mari- juana overactivates the endocannabinoid system, causing the high and other ef- fects that users experience. These in- clude distorted perceptions, impaired coordination, difficulty with thinking and problem solving, and disrupted learning and memory. Effects on Life Research clearly demonstrates that marijuana has the potential to cause problems in daily life or make a per- son's existing problems worse. In fact, heavy marijuana users generally re- port lower life satisfaction, poorer mental and physical health, relation- ship problems, and less academic and career success compared to their peers who came from similar back- grounds. For example, marijuana use is associated with a higher likelihood of dropping out from school. Several studies also associate workers' mariju- ana smoking with increased absences, tardiness, accidents, workers' com- pensation claims, and job turnover. Research has shown that, in chronic us- ers, marijuana's adverse impact on learning and memory persists after the acute effects of the drug wear off; when marijuana use begins in adolescence, the effects may persist for many years. Re- search from different areas is converging on the fact that regular marijuana use by young people can have long- lasting nega- tive impact on the structure and function of their brains. A recent study of marijuana users who began using in adolescence revealed a profound deficit in connections between brain areas responsible for learning and memory. And a large prospective study (following individuals across time) showed that people who began smoking marijuana heavily in their teens lost as much as 8 points in IQ between age 13 and age 38; importantly, the lost cogni- tive abilities were not restored in those who quit smoking marijuana as adults. (Individuals who started smoking mari- juana in adulthood did not show signifi- cant IQ declines.) What Are the Other Health Effects of Marijuana? Marijuana use can have a variety of ad- verse, short- and long- term effects, espe- cially on cardiopulmonary and mental health. Marijuana raises heart rate by percent shortly after smoking; this effect can last up to 3 hours. In one study, it was estimated that marijuana users have a 4.8- fold increase in the risk of heart at- tack in the first hour after smoking the drug. This may be due to increased heart rate as well as the effects of marijuana on heart rhythms, causing palpitations and arrhythmias. This risk may be great- er in older individuals or in those with cardiac vulnerabilities. Marijuana and Driving Because it seriously impairs judgment and motor coordination, marijuana al- so contributes to accidents while driv- ing. A recent analysis of data from several studies found that marijuana use more than doubles a driver s risk of being in an accident. Further, the combination of marijuana and alcohol is worse than either substance alone with respect to driving impairment. Marijuana smoke is an irritant to the lungs, and frequent marijuana smokers can have many of the same respiratory problems experienced by tobacco smok- ers, such as daily cough and phlegm pro- duction, more frequent acute chest ill- Marijuana December 2012 Page 2

40 ness, and a heightened risk of lung infec- tions. One study found that people who smoke marijuana frequently but do not smoke tobacco have more health prob- lems and miss more days of work than Is Marijuana Medicine? Although many have called for the le- galization of marijuana to treat condi- tions including pain and nausea caused by HIV/AIDS, cancer, and other conditions, the scientific evidence to date is not sufficient for the marijuana plant to gain FDA approval, for two main reasons. First, there have not been enough clin- ical trials showing that marijuana s benefits outweigh its health risks in patients with the symptoms it is meant to treat. The FDA requires care- fully conducted studies in large num- bers of patients (hundreds to thou- sands) to accurately assess the bene- fits and risks of a potential medication. Also, to be considered a legitimate medicine, a substance must have well- defined and measureable ingredients that are consistent from one unit (such as a pill or injection) to the next. This consistency allows doctors to de- termine the dose and frequency. As the marijuana plant contains hundreds of chemical compounds that may have different effects and that vary from plant to plant, its use as a medicine is difficult to evaluate. However, THC- based drugs to treat pain and nausea are already FDA ap- proved and prescribed, and scientists continue to investigate the medicinal properties of cannabinoids. For more information, see ns/drugfacts/marijuana- medicine nonsmokers, mainly because of respira- tory illnesses. A number of studies have shown an as- sociation between chronic marijuana use and mental illness. High doses of mariju- ana can produce a temporary psychotic reaction (involving hallucinations and paranoia) in some users, and using mari- juana can worsen the course of illness in patients with schizophrenia. A series of large prospective studies also showed a link between marijuana use and later development of psychosis. This relation- ship was influenced by genetic variables as well as the amount of drug used and the age at which it was first taken those who start young are at increased risk for later problems. Associations have also been found be- tween marijuana use and other mental health problems, such as depression, anxiety, suicidal thoughts among adoles- cents, and personality disturbances, in- cluding a lack of motivation to engage in typically rewarding activities. More re- search is still needed to confirm and bet- ter understand these linkages. Marijuana use during pregnancy is asso- ciated with increased risk of neurobe- havioral problems in babies. Because THC and other compounds in marijuana mimic the body s own cannabinoid- like chemicals, marijuana use by pregnant mothers may alter the developing endo- cannabinoid system in the brain of the fetus. Consequences for the child may in- clude problems with attention, memory, and problem solving. Finally, marijuana use has been linked in a few recent studies to an increased risk of an aggressive type of testicular cancer in young men, although further research is needed to establish whether there is a direct causal connection. Is Marijuana Addictive? Marijuana December 2012 Page 3

41 Contrary to common belief, marijuana is addictive. Estimates from research sug- gest that about 9 percent of users be- come addicted to marijuana; this num- ber increases among those who start young (to about 17 percent, or 1 in 6) and among daily users (to per- cent). Thus, many of the nearly 7 percent of high- school seniors who (according to annual survey data) report smoking ma- rijuana daily or almost daily are well on their way to addiction, if not already ad- dicted (besides functioning at a sub- optimal level all of the time). Long- term marijuana users trying to quit report withdrawal symptoms including irritability, sleeplessness, decreased ap- petite, anxiety, and drug craving, all of which can make it difficult to remain ab- Rising Potency The amount of THC in marijuana samples confiscated by police has been increasing steadily over the past few decades. In 2009, THC con- centrations in marijuana averaged close to 10 percent, compared to around 4 percent in the 1980s. For a new user, this may mean exposure to higher concentrations of THC, with a greater chance of an adverse or un- predictable reaction. Increases in po- tency may account for the rise in emergency department visits involv- ing marijuana use. For experienced users, it may mean a greater risk for addiction if they are exposing them- selves to high doses on a regular ba- sis. However, the full range of conse- quences associated with marijuana's higher potency is not well under- stood, nor is it known whether expe- rienced marijuana users adjust for the increase in potency by using less. stinent. Behavioral interventions, includ- ing cognitive- behavioral therapy and motivational incentives (i.e., providing vouchers for goods or services to pa- tients who remain abstinent) have prov- en to be effective in treating marijuana addiction. Although no medications are currently available, recent discoveries about the workings of the endocanna- binoid system offer promise for the de- velopment of medications to ease with- drawal, block the intoxicating effects of marijuana, and prevent relapse. Learn More For additional information on marijuana and marijuana abuse, please see s/research- reports/marijuana- abuse Marijuana December 2012 Page 4

42 Is Marijuana Medicine? The use of marijuana to treat various medical conditions or medical mariju- ana is a controversial topic and has been for some time. Some people have argued that marijuana s reported benefi- cial effects on a variety of symptoms jus- tify its legalization as a medicine for cer- tain patients. Often the potential harm of marijuana use is not considered in these arguments, although risk is part of what the U.S. Food and Drug Administration (FDA) assesses when deciding whether to approve a medicine. Under Federal law, only FDA- approved medications are legal to prescribe and marijuana is not one of those. Still, more than a dozen States have approved its use to alleviate a variety of symptoms. What Does Marijuana Do to the Body? Many of marijuana s effects (including its psychoactive or mind- altering proper- ties) stem from an ingredient called del- ta- 9- tetrahydrocannabinol (THC), which resembles a chemical that the body and brain make naturally (see figure). THC attaches to specialized proteins, called cannabinoid receptors (CBRs), to which the body s natural chemicals (e.g., anan- damide) normally bind. THC's chemical structure is similar to the brain chem- ical anandamide. Similarity in structure allows drugs to be recognized by the body and to alter normal brain communication. CBRs are part of a vast communication network known as the endocannabinoid system (ECS), which plays a role in nor- mal brain development and function. They cluster in brain areas that influence pleasure, memory, thinking, concentra- tion, movement, coordination, and sen- sory and time perception. When someone smokes marijuana, THC stimulates the CBRs artificially, disrupt- ing function of the natural cannabinoids. An overstimulation of these receptors in key brain areas produces the marijuana "high" as well as its other effects on men- tal processes. Marijuana Used for Medical Purposes July 2012 Page 1