CHAPTER 2
DRUGS OF ABUSE—ORIGINS, USES, AND EFFECTS

SCHEDULING OF DRUGS

The federal strategy to reduce illicit drug use is based on the Comprehensive Drug Abuse Prevention and Control Act of 1970, Title II (PL 91-513)—commonly called the Controlled Substances Act. This act establishes the criteria for "scheduling," or categorizing, all substances regulated under existing federal law. (See Table 2.1.)

• Schedule I—These drugs have a high potential for abuse and have no currently accepted medical use in treatment in the United States. Included in this class are heroin; most hallucinogens, such as LSD and MDMA (Ecstasy); and the members of the cannabis family, including marijuana and hashish.
• Schedule II—These drugs also have a high potential for abuse but have been accepted for medical use in the United States, with severe restrictions. Abuse of these drugs may lead to severe psychological or physical dependence. Opium, morphine, PCP, methamphetamine, methadone, certain barbiturates, and cocaine are some of the drugs in this schedule. A number of painkillers that were once Schedule III substances, including oxycodone and hydrocodone, were reclassified as Schedule II in 2004.
• Schedule III—The drugs in this class have less potential for abuse than those in the first two schedules. They are currently accepted for medical use in the United States, but abuse may lead to moderate or low physical dependence or high psychological dependence. Included in this category are anabolic steroids and some barbiturates.
• Schedule IV—These drugs have even less potential for abuse than those in Schedule III and are currently accepted for medical use in the United States. Abuse may lead to limited physical and psychological dependence. Darvon, Equanil, Valium, and Xanax are included here.
• Schedule V—These drugs have a lower potential for abuse than those in Schedule IV. They are accepted for medical use, but abuse may lead to limited physical or psychological dependence. Some narcotics used for antidiarrheal or antitussive (cough suppressing) purposes are included here.

While less addictive than Schedule I and II drugs, Schedule III, IV, and V drugs can be very dangerous to an abuser's health. A significant black market has developed for these drugs. Drug abusers visit their doctors complaining of a problem they know will likely be treated by a drug they desire. If the physician is fooled, he or she writes a prescription, which the drug abuser has filled at a pharmacy. The abuser then either uses the drugs personally or sells them to another addict.

Considerations in Determining the Schedule

According to the Drug Enforcement Administration (DEA) (http://www.usdoj.gov/dea/pubs/csa/811.htm#c], in structuring the regulatory requirements shown in Table 2.2, federal agencies must first consider eight specific factors:

• The drug's actual or relative potential for abuse.
• Scientific evidence of its pharmacological effect, if known.
• The state of current scientific knowledge about the drug.
• Its history and current pattern of abuse.
• The scope, duration, and significance of abuse.
• The risk, if any, to public health.
• The drug's psychological or physiological "dependence liability" (the chance that the user may become addicted to it).
• The substance's potential to be a source for a drug already regulated under federal law.

NATURAL NARCOTICS

Narcotics are opium, opium derivatives, or synthetic substitutes used medically to relieve intense pain. (See Table 2.1.) The main source of nonsynthetic narcotics is resin from the poppy Papaver somniferum. (See Figure 2.1.) Opium gum is produced from the resin, which is scraped by hand from cut, unripe seedpods and air-dried.

A more modern method of harvesting, known as the industrial poppy straw process, involves extracting alkaloids (organic compounds found in living organisms) from the mature dried plant. The extract may be in a number of forms. Most poppy straw concentrate made available commercially is a fine brownish powder with a distinct odor.

Opium

Opium can come in several forms, but it usually appears as dark brown chunks or powder that can be either smoked or eaten. The DEA claims that there is little opium abuse in this country because of laws governing the production and distribution of narcotic substances. Numerous drugs derived from or chemically similar to opium, however, are popular in the United States.

At least twenty-five alkaloids, divided into two general categories, can be extracted from opium (Dzulkfli Abdul Razak, "Narcotic Abuse: Effects and Treatment," http://www.prn2.usm.my/mainsite/bulletin/sun/1996/sun30.html). Drugs of the first type, represented by morphine and codeine, are used as analgesics (pain relievers) and cough suppressants, and are known as phenanthrene alkaloids. Those in the second group, isoquinoline alkaloids, are used as intestinal relaxants and also as cough suppressants.

Isoquinoline alkaloids have no significant influence on the central nervous system and are not regulated under the Controlled Substances Act. Virtually all of the opium imported into this country is broken down into alkaloid constituents—principally morphine and codeine.

Morphine

Morphine is one of the most effective drugs known for pain relief. It is marketed in the form of oral solutions, sustained-release tablets, and injectable preparations. It is odorless, bitter, and darkens with age. Morphine can be administered orally, subcutaneously, intramuscularly, or intravenously, the latter method being the one most frequently used by drug addicts. Tolerance and dependence develop rapidly in the user.

Morphine is used legally only in hospitals or hospices, usually to control the severe pain resulting from such illnesses as cancer. Only a small portion of the morphine obtained from opium is used medicinally; most is converted to codeine and, secondarily, to hydromorphone, a powerful pain killer.

Codeine

Codeine is found in raw opium. Although it occurs naturally, most is produced from morphine. Compared with morphine, codeine produces less pain relief but also produces less sedation and respiratory depression. It is used for moderate pain relief by itself or combined with other products, such as aspirin or acetaminophen (Tylenol). Robitussin AC and Cheracol are examples of liquid codeine preparations. According to the DEA, codeine is the most widely used naturally occurring narcotic in medical treatment.

SEMISYNTHETIC NARCOTICS

Semisynthetic narcotics are derived by altering chemicals contained in opium. The two most commonly produced are heroin and hydromorphone.

Heroin

Heroin was first synthesized from morphine in 1874 but was not used extensively until the Bayer Company of Germany first began commercial production in 1898. It was widely accepted as a painkiller for years, with the medical profession largely unaware of its potential for addiction. The Harrison Narcotic Act of 1914 established control of heroin in the United States.

Pure heroin, a bitter white powder, is usually dissolved and injected. Heroin found "on the street" may vary in color from white to dark brown depending on the amount of impurities left from the manufacturing process or the presence of additives, such as food coloring, cocoa, or brown sugar.

For many years, the typical "bag" (single dose) of street heroin weighed about 100 milligrams and frequently contained less than 10% actual heroin, with the remainder made up of sugar, starch, powdered milk, or quinine. By the 1990s, however, the national average of heroin purity ranged between 35 and 40%, according to the DEA. In 1997 the highest-purity heroin was reported in cities in the Northeast, such as Philadelphia (79.5%) and New York City (62.5%).

"Black tar" heroin is popular in the western United States. A crudely processed form of heroin, black tar is manufactured illegally in Mexico and derives its name from its sticky, dark brown or black appearance. According to USNoDrugs.com, black tar is often sold on the street in its tar-like state and can have purities ranging from 20 to 80%. It can be diluted with substances such as burnt cornstarch or converted into a powder. It is most commonly injected.

Until recently, heroin was usually injected—intravenously (the preferred method), subcutaneously ("skin popping"), or intramuscularly. The increased availability of high-purity heroin, however, meant that users could snort or smoke the drug, which contributed to an increase in heroin use. Snorting or smoking is more appealing to those users who fear contracting diseases like human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) and hepatitis through shared syringes; users who smoke or snort heroin also avoid the historical stigma attached to heroin use—the marks of the needle left on one's skin. Once hooked, however, many abusers who started by snorting or smoking the drug shift to intravenous use.

Because of the increased availability of heroin, the price of the drug dropped—in the 1990s street-level prices were generally $10 to $20 a bag, or even less, according to the National Institute on Drug Abuse (NIDA). The National Drug Intelligence Center, in its National Drug Threat Assessment 2005: Threat Matrix, put the 2005 street price of heroin at $10 per dose. Heroin use has increased in recent years, and officials believe the increase is primarily due to lower prices, greater availability, and higher purity.

SYMPTOMS AND RELATED PROBLEMS.

Symptoms and signs of heroin use include euphoria, drowsiness, respiratory depression, constricted pupils, and nausea. Withdrawal symptoms include watery eyes, runny nose, yawning, loss of appetite, tremors, panic, chills, sweating, nausea, diarrhea, muscle cramps, and insomnia. Elevations in blood pressure, pulse, respiratory rate, and temperature occur as withdrawal progresses. Because heroin abusers are often unaware of the actual strength of the drug and its true contents, they are at risk of overdose. Symptoms of overdose, which may result in death, include shallow breathing, clammy skin, convulsions, and coma. According to the Substance Abuse and Mental Health Services Administration, which is part of the U.S. Department of Health and Human Services, heroin is one of the most frequently reported drugs in drug-abuse deaths, either singly or in combination with cocaine and/or alcohol.

Sharing unsterilized needles with other addicts increases the risk of exposure to HIV, the virus that causes AIDS. The use of heroin, as well as the self-abusing lifestyle that often accompanies its use, may compromise the body's ability to withstand infection, compounding the devastating effects of HIV. As a result, drug abusers have become one of the fastest-growing groups of HIV sufferers in the United States.

Pregnant women addicted to heroin often give birth to addicted babies. These babies must go through painful withdrawal and may not develop normally. Some women give birth to children carrying HIV, some of whom will eventually develop AIDS. In addition, children born to addicted mothers are at greater risk of sudden infant death syndrome (SIDS), a disorder in which infants suddenly and inexplicably stop breathing and die.

Hydromorphone

Commonly called by the trade name Dilaudid, hydromorphone is the second-oldest semisynthetic narcotic painkiller. It is shorter-acting, more sedating, and two to eight times more intense than morphine. Easily abused, it is sought after by addicts—usually through theft or fraudulent prescriptions. Hydromorphone tablets, which are stronger than liquid forms of the drug, may be dissolved and injected.

SYNTHETIC NARCOTICS

Unlike products derived directly or indirectly from narcotics of natural origin, synthetic narcotics are produced entirely in the laboratory. The primary objective of laboratory production is to produce a drug that will have the analgesic properties of morphine while minimizing the potential for addiction. The products most widely available—hydrocodone, oxycodone, meperidine, and methadone—are still addictive however.

Hydrocodone and Oxycodone

Hydrocodone and oxycodone are two of the most commonly prescribed narcotic painkillers in the United States. Although they are designed to have less euphoric effect than morphine, they are still highly sought after by recreational users and addicts. Like morphine, these drugs have enough potential for abuse that they are classified as Schedule II substances. (See Table 2.1.)

In 2001 the drug OxyContin, produced by Purdue Pharma L.P., received an enormous amount of media attention. Although the active ingredient, oxycodone, has been around for a long time in drugs such as Percocet and Percodan, media and law enforcement noted a new wave of use. OxyContin, which is sold in high-dosage time-release pills, can be easily swallowed, chewed, or even crushed and injected, for a heroin-like high. The manufacturer, after DEA pressure, agreed to try to produce its product in ways that had less potential for abuse. As of 2003, however, abuse of OxyContin was still on the rise, according to the National Drug Intelligence Center.

Meperidine (Pethidine)

First introduced in the 1930s, meperidine parallels morphine's pain-relieving strength. It is the most widely used drug for relief of moderate to severe pain and is frequently used during childbirth and after operations. Tolerance and dependence develop with chronic use, and large doses can result in convulsions. Demerol and Pethadal are meperidine products.

Methadone and Related Drugs

Methadone was first synthesized by German scientists during World War II because of a shortage of morphine. Although its chemical makeup is unlike that of morphine or heroin, it produces many of the same effects as those drugs. It was introduced to the United States in 1947 and became widely used in the 1960s to help treat narcotic addicts.

The effects of methadone last up to twenty-four hours, and the drug is almost as effective when administered orally as by injection. Tolerance and dependence can develop, and in some metropolitan areas, methadone has become just another illegal drug. It has also emerged as an important cause of overdose deaths.

Levo-alpha-acetylmethadol (LAAM) is a closely related synthetic compound with an even longer duration of action (forty-eight to seventy-two hours), allowing for fewer clinic visits and eliminating take-home medication. In 1994 it was approved for use in the treatment of narcotic addiction. Another close relative of methadone is dextropropoxyphene, first marketed in 1957 under the trade name Darvon for the relief of mild to moderate pain. There is less chance of dependence, but also less pain relief. It has one-half to one-third the potency of codeine but is about ten times stronger than aspirin. Because of misuse, bulk dextropropoxyphene was placed in Schedule II, while preparations containing it are in Schedule IV. (See Table 2.1.)

DEPRESSANTS

The Controlled Substances Act regulates depressants because they have a high potential for abuse and are associated with both physical and psychological dependence. Taken as prescribed by a physician, depressants may be beneficial for the relief of anxiety, irritability, and tension, as well as for the symptomatic relief of insomnia. When taken in excessive amounts, however, they produce a state of intoxication very similar to that of alcohol. Unlike most other illegal drugs, depressants (except for methaqualone) are rarely produced in secret laboratories. Instead, they are generally obtained through theft and fraudulent prescriptions and sold illegally on the black market.

Chloral Hydrate

The oldest of the hypnotic (sleep-inducing) drugs, chloral hydrate was first synthesized in 1832 and soon replaced alcohol, opium, and cannabis for bringing about sedation and sleep. Its effects are similar to those of alcohol, and withdrawal symptoms resemble delirium tremens (the "DTs"). Cases of poisoning have occurred from mixing chloral hydrate with alcohol. Older adults are the most common abusers of this drug; it is not a street drug of choice.

Barbiturates

According to Charles E. Ophardt in Virtual Chembook (http://www.elmhurst.edu/~chm/vchembook/6673barbit.html), about twenty-five hundred derivatives of barbituric acid have been synthesized, but only fifteen are used medically. Small therapeutic doses calm nervous conditions; larger doses cause sleep within a short period of time. A feeling of excitement precedes the sedation. Too large a dose can bring a person through stages of sedation, sleep, and coma and ultimately cause death via respiratory failure and cardiovascular complications.

Barbiturates are classified as ultrashort-, short-, intermediate-, and long-acting. Ultrashort-acting barbiturates produce anesthesia within one minute of intravenous delivery into the system. Pentathol, Brevital, and Surital are among those currently in medical use. Because of the rapid onset and brief duration of effect, drug abusers find these drugs unattractive.

Short-acting and intermediate-acting barbiturates, including Nembutal, Seconal, and Amytal, with durations of up to six hours, are much more in demand by thrill-seekers. Long-acting barbiturates, such as Veronal, Luminal, and Mebaral, have onset times of up to one hour and durations of up to sixteen hours. These are used medicinally as sedatives, hypnotics, and anticonvulsants.

Glutethimide and Methaqualone

Glutethimide (Doriden) was introduced in 1954 and methaqualone (Quaalude, Sopor) in 1965 as safe substitutes for barbiturates. Usually prescribed for pain and sleep disturbance, in medically approved doses they cause feelings of calm, drowsiness, and euphoria. They are administered orally; in large doses they can cause tremors and altered sleep patterns. In 1991 glutethimide was transferred to Schedule II because of its potential for abuse.

Not long after its introduction, methaqualone became a drug of choice among drug users who thought it was both nonaddictive and an aphrodisiac. Extensive use and abuse of methaqualone can cause hallucinations, anxiety, numbness, tingling, and even serious poisoning. In 1984 the United States stopped production and distribution of methaqualone pharmaceutical products because of growing abuse, and the drug was transferred to Schedule I of the Controlled Substances Act. Counterfeit copies containing diazepam (Valium), flurazepan, and phenobarbital are prevalent on the U.S. illicit drug market.

Benzodiazepines

Benzodiazepines are depressants that relieve anxiety, tension, and muscle spasms; produce sedation; and prevent convulsions. They have a relatively slow onset but long duration of action. They also have a greater margin of safety than other depressants. According to the DEA, benzodiazepines are among the most widely prescribed medications in the United States. Xanax (alprazolam), Librium (zepoxide), and Valium (diazepam) are in this group.

Prolonged use of excessive doses may result in physical and psychological dependence. Because benzodia-zepines are eliminated from the body slowly, withdrawal symptoms generally develop slowly, usually seven to ten days after continued high doses are stopped. When these drugs are used illicitly, they are often taken with alcohol or marijuana to achieve a euphoric "high." Since benzodiazepines are legal, they are usually obtained by getting prescriptions from doctors or forging prescriptions. They are also bought illegally on the black market.

Rohypnol (flunitrazepam), another benzodiazepine, has become increasingly popular among young people. The drug, manufactured as a short-term treatment for severe sleeping disorders, is not marketed legally in the United States and must be smuggled in. It is widely known as a "date-rape drug," because would-be rapists have been known to drop it secretly into a woman's drink to facilitate sexual assault. Several states—including Florida, Idaho, Minnesota, New Mexico, North Dakota, Oklahoma, and Pennsylvania—placed the drug under Schedule I control, and the United States has banned its importation and imposed stiff federal penalties for its sale. Responding to pressure from the American government, the Mexican producer of Rohypnol, Roche, began putting a blue dye in the pill so that it could be seen when dissolved in a drink.

STIMULANTS

Potent stimulants make users feel stronger, more decisive, and self-possessed. Because of the buildup effect, chronic users often develop a pattern of using "uppers" in the morning and "downers," such as alcohol or sleeping pills, at night. Such manipulation interferes with normal body processes and can lead to mental and physical illness.

Large doses can produce paranoia and auditory and visual hallucinations. Overdoses can also produce dizziness, tremors, agitation, hostility, panic, headaches, flushed skin, chest pain with palpitations, excessive sweating, vomiting, and abdominal cramps. Chronic high-dose users exhibit profound depression, apathy, fatigue, and disturbed sleep for up to twenty hours when going through withdrawal, which may last for several days.

Cocaine

Cocaine, the most potent stimulant of natural origin, is extracted from the leaves of the coca plant (Erythroxylon coca), which has been cultivated in the Andean highlands of South America since prehistoric times. The coca leaves are frequently chewed for refreshment and relief from fatigue—in much the same way some North Americans chew tobacco.

According to the Office of National Drug Control Policy (http://www.whitehousedrugpolicy.gov/drugfact/cocaine/), pure cocaine was first isolated in the 1880s and used as a local anesthetic in eye surgery. In the late nineteenth and early twentieth centuries it became popular in this country as an anesthetic for nose and throat surgery. Since then, other drugs, such as lidocaine and novocaine, have replaced it as an anesthetic.

Illicit cocaine is distributed as a white crystalline powder, often contaminated, or "cut," with sugars or local anesthetics. (See Figure 2.2.) The drug is commonly sniffed, or "snorted," through the nasal passages. Less commonly, it is mixed with water and injected, which brings a more intense high because the drug reaches the brain more rapidly.

For some time, people thought cocaine was relatively safe from undesirable side effects—not true for those who become heavy users. Cocaine produces a very short but extremely powerful rush of energy and confidence. Because the pleasurable effects are so intense, cocaine can lead to severe mental dependency, destroying a person's life as the need for the drug supersedes any other considerations. Physically, cocaine users risk permanent damage to their noses by exposing the cartilage and dissolving the nasal septum (membrane), resulting in a collapsed nose. Cocaine significantly increases the risk of heart attack in the first hour after use. Heavy use (two grams or more a week) impairs memory, decision making, and manual dexterity.

In the 1970s cocaine was popularly accepted as a recreational drug—particularly by the wealthy, who were among the few who could afford to use it. The coming years, however, would see a development that would bring cocaine to the masses: "crack."

Freebasing is a process in which dissolved cocaine is mixed with ether or rum and sodium hydroxide, or baking powder. The salt base dissolves, leaving granules of pure cocaine. These are next heated in a pipe until they vaporize. The vapor is inhaled directly into the lungs, causing an immediate high that lasts about ten minutes.

There is a danger of being badly burned if the open flame gets too close to the ether or the rum, causing them to flare up as they burn. When actor-comedian Richard Pryor set himself on fire while freebasing in 1980, many users started to search for a safer way to achieve the same high. The dangers inherent in freebasing may have been the catalyst for the development of crack cocaine.

Crack

Cocaine hydrochloride, the powdered form of cocaine, is soluble in water, can be injected, and is fairly insensitive to heat. When cocaine hydrochloride is converted to cocaine base, it yields a substance that becomes volatile when heated. "Crack" (as described by several government Web sites, including that of NIDA [http://www.nida.nih.gov/Infofacts/cocaine.html]) is processed by mixing cocaine with baking soda and heating it to remove the hydrochloride rather than by the more volatile method of using ether. The resultant chips, or "rocks," of pure cocaine are usually smoked in a pipe or added to a cigarette or marijuana joint. (See Figure 2.3 and Figure 2.4.) The name comes from the crackling sound made when the mixture is smoked.

Inhaling the cocaine fumes produces a rapid, intense, and short-lived effect. This incredible intensity is followed within minutes by an abnormally disconcerting and anxious "crash," which leads almost inevitably to the need for more of the drug—and a great likelihood of addiction.

MARKETING CRACK.

The mass marketing of crack began in the mid-1980s. A glut of powdered cocaine had saturated the market, driving down prices and cutting into dealers' profits. This coincided with the discovery of crack, which could "hook" users after just a few tries.

Experimenters in the Caribbean developed the first prototypes of crack by mixing cocaine with baking soda, water, and rum. At that time, most cocaine was being shipped to the United States through the extensive islands and bays of the Bahamas, and a sizable portion of it was being diverted to the local population.

When dealers saw the attraction that this new product had for Bahamian users, they were quick to realize the potential profits that could be made by introducing it on the streets of the United States—first in Miami, Los Angeles, and New York. Pushers in those cities began to offer crack at low prices, knowing that users would quickly become addicted and come back for more.

Once introduced in the mid-1980s, crack spread rapidly. The most convenient distribution method was to use inner-city street gangs; they were located in areas with the heaviest concentration of drug users. Crack sold for only $5 to $10 a hit and could more easily be sold to poor people living in these areas. Expanding from Miami, Los Angeles, and New York, crack spread across the nation through interstate and intrastate transport.

Although crack spread rapidly in the mid-1980s and received a lot of attention from the media and government, it faded from view somewhat in the 1990s. Crack use dropped throughout the 1990s as its devastating effects on users became widely known; users switched to other drugs, and new users were difficult for pushers to attract—they had been scared away. News stories stopped appearing, and the government began to focus its attention on other drugs, such as methamphetamine and Ecstasy.

Amphetamines

Amphetamines are synthetic drugs similar to the hormone adrenaline and the stimulant ephedrine. The history of the illicit use of amphetamines is very much like that of cocaine. As documented by the DEA, amphetamines were first marketed in the 1930s, under the name Benzedrine, in an over-the-counter inhaler to treat nasal congestion. Abuse of these inhalers soon became popular among teenagers and prisoners. In 1937 Benzedrine became available in pill form, and the number of abusers quickly increased.

Medically, amphetamines are used mainly to treat depression, narcolepsy (a rare disorder that causes people to fall asleep involuntarily), hyperactive disorders in children (now called attention deficit hyperactivity disorder, or ADHD), and certain cases of obesity. During World War II pilots took Benzedrine to stay awake.

"Speed freaks," who injected amphetamines, became famous in the drug culture for their strange and often violent behavior. In 1965 federal food and drug laws were amended to curb the growing black market in amphetamines. Many legal drugs using amphetamines were removed from the market, and doctors began prescribing them less frequently. As a result, clandestine laboratories increased their production to meet the growing black market demand. Today, most amphetamines are produced in these clandestine laboratories.

Extended amphetamine use can lead to a number of health problems. Short-term effects include sleeplessness, which can lead to and compound psychotic episodes brought on by heavy use. Long-term effects are unknown, although some research has suggested that chronic amphetamine use may contribute to neurological damage, such as the development of Parkinson's disease.

Methamphetamines

Methamphetamines are synthetic stimulants similar to amphetamines. As documented by NIDA, they were first developed by a Japanese pharmacologist in 1919. They came to market during the 1930s as a treatment for narcolepsy, attention deficit disorder, and obesity. A form of the drug often referred to as "speed" became popular during the 1960s and led to government control over the manufacture of the drug. Methamphetamine abuse fell off in the 1970s as cocaine became increasingly available. In the 1990s, however, its use increased dramatically, though use began to taper off somewhat again around the turn of the millennium.

Methamphetamines have traditionally been distributed by outlaw motorcycle gangs and other independent producers. While these groups still play a role in the drug's sale, traffickers operating out of Mexico have taken over major distribution. Using money raised from the sale of other drugs, they have built sophisticated new laboratories that produce large quantities of the drug. At first, these traffickers limited distribution to the western United States, but they have since expanded their distribution channels well into the Midwest.

Methamphetamines can be either injected or inhaled. To make the drug more attractive, Mexican traffickers have increased its purity. This has made it easier to inhale and, therefore, more attractive to potential users who might be concerned about the dangers of using syringes.

The effects of methamphetamines are similar to those of cocaine, but their onset is slower and they last longer. Methamphetamines cause increased activity, decreased appetite, and a sense of euphoria in the user. Abusers frequently become paranoid, pick at their skin, and suffer from auditory and/or visual hallucinations. Chronic abusers may exhibit violent and erratic behavior. Metham-phetamines are associated with such health conditions as memory loss and heart and brain damage. Crystallized methamphetamine hydrochloride, or "ice," is a smokable form of methamphetamine.

One of the key ingredients often used in the manufacture of methamphetamones is pseudoephedrine, a drug found in many common nasal decongestants, such as Sudafed. In 2005 this led some government officials to consider outlawing sale of these decongestants, which are currently available over the counter under many brand names.

Methcathinone—"Cat"

"Cat," or methcathinone, a more recent drug of abuse in the United States, was placed into Schedule I of the Controlled Substances Act in 1993. "Cat" is produced in clandestine laboratories and is usually snorted, although it can be mixed in a beverage and taken orally or diluted in water and injected intravenously.

Methcathinone has about the same abuse potential as methamphetamines and produces similar results: excessive energy, hyperactivity, extended wakefulness, and loss of appetite. The user feels both euphoric and invincible. At the same time, use of "cat" can lead to anxiety, tremors, insomnia, weight loss, sweating, stomach pains, a pounding heart, nose bleeds, and body aches. Excessive use can lead to convulsions, paranoia, hallucinations, and depression.

Phenmetrazine (Preludin) and
Methylphenidate (Ritalin)

Abuse patterns of these drugs are similar to those of other stimulants. Preludin is used medically as an appetite suppressant, and Ritalin, frequently prescribed by physicians, is used mainly to treat children with attention deficit disorders. These drugs are most subject to abuse in countries where they are easily available, such as in the United States.

Debates have arisen regarding the overprescription of Ritalin. The American Medical Association has estimated that as of 2003, four to eight million children in the United States were being treated with Ritalin for attention deficit disorders. Opponents of Ritalin prescription argue that the diagnosis of attention deficit hyperactivity disorder (ADHD) is simply a way of labeling children who make classroom management difficult and medicating them so they will stop acting out. Proponents argue that ADHD is a very serious medical condition and that stimulant drugs are necessary in helping children with the condition develop correctly. Experts on both sides agree that the ADHD diagnosis is sometimes applied—and medication prescribed—in cases where it is unnecessary.

Anorectic Drugs

These drugs are relatively recent attempts to replace amphetamines as appetite suppressants. They produce many of the same effects but are generally less potent. Abuse patterns have not been determined, but all drugs in this group are classified as controlled substances because of their similarity to amphetamines. They include Didrex, Pre-Sate, Tenuate, Tepanil, Pondimin, Mazanor, Ionamin, Adipex-P, and Sanorex.

Khat

Khat is a natural substance derived from the fresh young leaves of the Catha edulis shrub, native to East Africa and the Arabian peninsula. People in these areas have been chewing khat for centuries, often in communal social situations—the same way Americans drink coffee or tea. Chewed in moderation, khat alleviates fatigue and reduces appetite. Excessive use may result in paranoia and hallucinations. Khat contains many chemicals that are controlled substances, including cathinone (Schedule I) and cathine (Schedule IV).

HALLUCINOGENS

Hallucinogenic drugs, or psychedelics, are natural or synthetic substances that distort the perceptions of reality. They cause excitation, which can vary from a sense of well-being to severe depression. Time may appear to stand still, and forms and colors seem to change and take on new meaning. The heart rate may increase, blood pressure rise, and pupils dilate. The experience may be pleasurable or extremely frightening. The effects of hallucinogens vary from use to use and cannot be predicted.

The most common danger of using hallucinogens is impaired judgment, which can lead to rash decisions and accidents. Long after hallucinogens have been eliminated from the body, users may experience "flashbacks," in the form of perceived intensity of color, the apparent motion of fixed objects, or illusions that present one object when another one is present. Some hallucinogens are present in plants (e.g. mescaline in the peyote cactus); others, such as LSD, are synthetic. The abuse of hallucinogens in the United States peaked in the late 1960s, but the 1990s and early 2000s saw a resurgence in the use of these drugs.

Peyote and Mescaline

Mescaline is a psychoactive chemical found naturally in the peyote cactus, Lophophor williamsii, a small, spineless plant native to Mexico and the southwestern United States. The top of the cactus, often called the crown, is made up of disk-shaped buttons that can be cut off and dried. These buttons are generally chewed or soaked in water to produce an intoxicating liquid. A dose of 350 to 500 milligrams produces hallucinations lasting from five to twelve hours. Mescaline can be extracted from peyote or produced synthetically.

Peyote and mescaline have long been used by American Indians in religious ceremonies. Recently, however, this use has come into serious question. In 1990 the U.S. Supreme Court, in Employment Division, Department of Human Resources v. Smith (494 US 872), ruled that the state of Oregon could bar the Native American Church fromusing peyote in its religious ceremonies. The passage of the Religious Freedom Restoration Act of 1993 (PL 103-141) allowed the church to use peyote in those ceremonies; but in 1997 the Supreme Court, in Boerne v. Flores (65 LW 4612), declared the Religious Freedom Restoration Act unconstitutional. This left the use of peyote back in the jurisdiction of the states, and states may decide individually on its use.

Arizona law allows the use of peyote in connection with the practice of a religious belief if it is an integral part of a religious exercise and if it is used in a manner not dangerous to public health. Several other states, mainly in the Southwest, continue to allow the use of peyote in religious ceremonies if certain conditions are met, such as Native American origin or proof of religious affiliation. In general, in most states that allow peyote use, the Native American Church is the only recognized organization with a bona fide claim that peyote is a sacrament in its rituals.

DOM, DOB, MDA, MDMA, and "Designer Drugs"

DOM (4-methyl-2,5-mimethoxyamphetamine), DOB (4-bromo-2,5-dimethoxyamphetamine), MDA (3,4-methylenedioxyamphetamine), MDMA (3,4 methylenedioxy-methamphetamine), and "designer drugs" are chemical variations of mescaline and amphetamines that have been synthesized in the laboratory. They differ from one another in speed of onset, duration of action, and potency. They are usually taken orally, are sometimes snorted, but they are rarely injected intravenously.

Because they are produced illegally, these drugs are seldom pure. Dosage quantity and quality vary considerably. These drugs are often used at "raves"—large, all-night dance parties once held in unusual places such as warehouses or railroad yards. Although many raves became mainstream events, professionally organized and held at public venues, the underground style and culture of raves remains an alluring draw to many teenagers. Part of the allure is drug use.

The most noted designer drug, MDMA (also called ADAM, Ecstasy, or X) was first banned by the DEA in 1985. Widespread abuse placed it in Schedule I of the Controlled Substances Act. Some doctors suggest that the pure form of the drug is not as harmful as one might think and may even have potential uses as an antidepressant or antipsychotic drug. However, the form of the drug found on the street is rarely a pure form. According to an October 2002 article in Pediatrics (Eric Sigel, "Club Drugs: Nothing to Rave About," vol. 19, no. 10), tablets of MDMA that have been tested have contained from zero to 140 milligrams of MDMA, as well as additional drugs such as ephedrine, dextromethorphan, or amphetamine.

Users of MDMA have been known to suffer serious psychological effects—including confusion, depression, sleep problems, drug craving, severe anxiety, and paranoia—both during, and sometimes weeks after, taking the drug. Physical symptoms include muscle tension, involuntary teeth clenching, nausea, blurred vision, rapid eye movement, faintness, and chills or sweating. Severe dehydration, particularly among users who dance for hours while under the drug's influence, is also a serious hazard.

MDA, the parent drug of MDMA, has been found to destroy serotonin-producing neurons, which play a direct role in regulating aggression, mood, sexual activity, sleep, and pain sensitivity. This may explain the sense of heightened sexual experience, tranquility, and conviviality said to accompany MDA use. The Anti-Drug Abuse Act of 1986 (PL 99-570) made all designer drugs illegal. By 2004, as reported by the University of Michigan News Service (http://www.umich.edu/news/?BG/ecstasy_cocaine), use of Ecstasy was on the decline, along with the novelty of the rave culture that helped give rise to its spread.

LSD (LSD-25, Lysergide)

LSD, an abbreviation of the German term for lysergic acid diethylamide, is one of the most potent mood-changing chemicals in existence. It is often called "acid." Odorless, colorless, and tasteless, it is produced from a substance derived from ergot fungus or from a chemical found in morning glory seeds. Both chemicals are found in Schedule III of the Controlled Substances Act while LSD itself is a Schedule I substance.

LSD is usually sold in tablets ("microdots"), thin squares of gelatin ("window panes"), or impregnated paper ("blotter acid"). Effects of doses higher than thirty to fifty micrograms can persist for ten to twelve hours, severely impairing judgment and decision-making. Tolerance develops rapidly, and more of the drug is needed to achieve the desired effect.

Dr. Albert Hoffman originally synthesized LSD in 1938, but it was not until 1943 that he accidentally took the drug and recorded his "trip." He was aware of vertigo and an intensification of light. During the two-hour experience, he also saw a stream of fantastically vivid images, coupled with an unusual play of colors.

Because of its structural similarity to a chemical present in the brain, LSD was originally used as a research tool to study the mechanism of mental illness. It was later adopted by the drug culture of the 1960s. During the 1960s LSD use was seen by users and nonusers alike as central to full participation in the emerging counterculture movement. Such major icons as author Ken Kesey and Harvard professor Timothy Leary began to promote a culture in which certain political values and drug use were almost synonymous.

LSD use dropped in the 1980s but showed a resurgence in the 1990s. It is inexpensive (according to the DEA, $1 to $10 per dosage unit—usually twenty to eighty micrograms), nonaddictive, and one hit can last for eight to twelve hours. Many young people have rediscovered the drug, taking it in a liquid form dropped on the tongue or in the eyes with an eye dropper, or by placing impregnated blotter paper on their tongues.

Phencyclidine (PCP) and Related Drugs

Many drug-treatment professionals believe that phencyclidine (PCP) poses greater risks to the user than any other drug. PCP was originally investigated in the 1950s as an anesthetic but was discontinued for human use because of its side effects, which included confusion and delirium. The drug is still occasionally used on animals, but even many veterinarians are now turning away from it.

In the United States virtually all PCP is manufactured in clandestine laboratories and sold on the black market. This drug is sold under at least fifty different names, many of which reflect its bizarre and volatile effects: Angel Dust, Crystal, Supergrass, Killer Weed, Embalming Fluid, Rocket Fuel, and others. It is often sold to users who think they are buying mescaline or LSD.

In its pure form, PCP is a white crystalline powder that readily dissolves in water. It can also be taken in tablet or capsule form. It can be swallowed, sniffed, smoked, or injected. It is commonly applied to a leafy material, such as parsley, mint, oregano, or marijuana, and smoked.

Because PCP is an anesthetic, it produces an inability to feel pain, which can lead to serious bodily injury. Unlike other hallucinogens, PCP produces depression in some individuals. Regular use often impairs memory, perception, concentration, motor movement, and judgment. PCP can also produce a psychotic state in many ways indistinguishable from schizophrenia, or it can lead to hallucinations, mood swings, paranoia, and amnesia.

Because of the extreme psychic disorders associated with repeated use, or even one dose, of PCP and related drugs, Congress passed the Psychotropic Substances Act of 1978 (PL 95-633). The penalties imposed for the manufacture or possession of these chemicals are the stiffest of any nonnarcotic violation under the Controlled Substances Act.

CANNABIS

Cannabis sativa, the hemp plant from which marijuana is made, grows wild throughout most of the world's tropic and temperate regions, including Mexico, the Middle East, Africa, and India. (See Figure 2.5.) For centuries, its therapeutic potential has been explored, including uses as an analgesic and anticonvulsant. But with the advent of new, synthetic drugs and the passage of the Marijuana Tax Act of 1937, interest in marijuana—even for medicinal purposes—faded. In 1970 the Controlled Substances Act classified marijuana as a Schedule I drug, having "no currently accepted medical use in treatment in the United States," though this classification is debated by those in favor of using it for medical and recreational purposes.

Cannabis plants are usually smoked in the form of loosely rolled cigarettes ("joints") or in various kinds of pipes. The effects are felt within minutes, usually peaking in ten to thirty minutes and lingering for two to three hours. Low doses induce restlessness and an increasing sense of well-being, followed by a dreamy state of relaxation and, frequently, hunger. Changes in sensory perception—a more vivid sense of sight, smell, touch, taste, and hearing—may occur, with subtle alterations in thought formation and expression. Drugs made from the cannabis plant are widely distributed on the U.S. black market.

Marijuana

Marijuana is a tobacco-like substance produced by drying the leaves and flowery top of the cannabis plant. (See Figure 2.5.) Its potency varies considerably, depending on how much of the chemical THC (delta-9-tetrahydrocannabinol) is present. The National Drug Intelligence Center estimates that wild U.S. cannabis has a THC content of less than 0.5%; it is considered inferior to Jamaican, Colombian, and Mexican varieties, whose THC content ranges between 0.5 and 0.7%.

The most potent form of marijuana is sinsemilla (Spanish for "without seed"), which comes from the unpollinated female cannabis plant and can contain up to 17% THC. Another potent form, Southeast Asian "Thai stick" (marijuana buds bound into short sections of bamboo), is not often found in the United States.

Marijuana is grown illegally throughout the United States, both indoors and out. Growers generally try to achieve the highest possible THC content in order to produce the greatest possible effect. It is thought that most marijuana smoked in the United States is grown in the United States, much of it in the Midwest using sophisticated hydroponic techniques (growing the plants in water instead of soil). Street names for marijuana include "pot," "grass," "weed," "Mary Jane," and "reefer."

USE AND EFFECTS.

Every survey the federal government conducts on drug use indicates that marijuana is by far the most extensively used illicit drug in the United States. During the 1960s and 1970s it was as common at many parties as beer and wine. In 2003 an estimated 96.6 million Americans—more than a third of the population age twelve and over—had tried marijuana at some point in their life, according to results from the National Survey on Drug Use and Health, conducted annually by the Substance Abuse and Mental Health Services Administration.

Extensive research by NIDA uncovered the effect that THC has on the hippocampus, a part of the brain that is crucial for learning, memory, and the integration of sensory experiences with emotions and motivation. Many feel that these studies, when taken together, may explain the euphoria and memory loss induced by marijuana, as well as provide definitive proof of the drug's toxic effect on brain cells.

Scientists at UCLA's Jonsson Comprehensive Cancer Center found in 1997 that smoking one to three marijuana cigarettes produces the same lung damage and potential cancer risk as smoking five times as many cigarettes. And NIDA, as shown on their Web site (http://www.nida.nih.gov/pdf/monographs/download44.html), reported as far back as 1984 that marijuana adversely affects reproductive function in both males and females.

The immediate physical effects of marijuana include a faster heartbeat (by as much as 50%), bloodshot eyes, and a dry mouth and throat. It can reduce short-term memory, alter one's sense of time, and reduce concentration and coordination. Some users experience light-headedness and giddiness, while others feel depressed and sad. Many users have also reported experiencing severe anxiety attacks.

Although symptoms usually disappear in about four to six hours, it takes about three days for 50% of the drug to be broken down and eliminated from the body. It takes three weeks to completely excrete the THC from one marijuana cigarette. If a user smokes two joints a week, it takes months for all traces of the THC to disappear from the body.

SUPPORT FOR PATIENT USE.

In the past marijuana has been used to treat glaucoma and several neurological disorders. However, an Institute of Medicine (IOM) report concluded that the drug was not useful in glaucoma treatment because its effects were short-lived (Janet E. Joy, Stanley J. Watson, Jr., and John A. Benson, Jr., Marijuana and Medicine: Assessing the Science Base, National Academies Press, 1999). The report also indicated that marijuana was ineffective in treating patients suffering from Parkinson's or Huntington's diseases. According to one of the principal investigators for the IOM, John Benson, Jr., the medical effects of marijuana are generally modest, and only patients who do not respond well to other medications should use it. Marijuana appears to be useful in treating conditions such as chemotherapy-induced nausea or the wasting caused by AIDS. It may also help relieve muscle spasms associated with multiple sclerosis.

In May 1991 nearly half of all cancer specialists who responded to an unofficial Harvard University survey said that they would prescribe marijuana for some of their patients if the drug were legal. A somewhat smaller percentage said that despite the drug's illegal status, they had already recommended it to patients as a means of enhancing appetite and relieving chemotherapy-related nausea.

As noted at the beginning of this chapter, one of the criteria used by the DEA in classifying drugs is whether there is a "currently accepted medical use in treatment in the United States." In 1988 Francis Young, the administrative judge of the DEA, noted that marijuana "in its natural form, is one of the safest therapeutically active substances known to man" and recommended that physicians be authorized to use it. The DEA refused to relax the restrictions.

In 1991 the Massachusetts Supreme Court, in Massachusetts v. Hutchins (49 CRL 1442), ruled that society's interest in preventing illegal drug use out-weighed a patient's "medical necessity" to use marijuana. The defendant, who began growing his own marijuana when he was unable to get government approval to use the drug to relieve the pain of his chronic illness, had been charged with possession and cultivation of the cannabis plant.

THE COURTS UPHOLD THE DEA ON MARIJUANA RESCHEDULING.

Over the past two decades a number of legal attempts have been made to get marijuana rescheduled from Schedule I, the most restrictive classification, to a less restrictive schedule. The first petition was filed in 1972 and reached the Court of Appeals of the District of Columbia four times: National Organization for the Reform of Marijuana Laws v. Ingersoll (497 F.2d 654, 1974), National Organization for the Reform of Marijuana Laws v. Drug Enforcement Administration (559 F.2d 735, 1977), National Organization for the Reform of Marijuana Laws v. Drug Enforcement Administration & Department of Health, Education and Welfare (No. 79-1660, 1980), and Alliance for Cannabis Therapeutics and The National Organization for the Reform of Marijuana Laws v. Drug Enforcement Administration (930 F.2d 936, 1991). All of these petitions failed.

In another attempt, Alliance for Cannabis Therapeutics and Drug Policy Foundation v. Drug Enforcement Administration (15 F.3d 1131, 1994), the petitioners claimed that the DEA had failed to recognize that "marijuana is misclassified because it has been shown to serve various medicinal purposes … marijuana alleviates some side effects of chemotherapy in cancer patients, aids in the treatment of glaucoma and eye diseases, and reduces muscle spasticity in patients suffering from multiple sclerosis and other maladies of the central nervous system" (Schaffer Library of Drug Policy, http://www.druglibrary.org/schaffer/hemp/medical/court_ruling.htm).

In support of their case, the petitioners submitted affidavits and testimonials from a number of patients and doctors who said marijuana had been helpful in treatment. The Food and Drug Administration (FDA) claimed that the testimonials were not scientific proof and that no scientific study had shown that marijuana was useful in medical treatment.

The FDA claimed that, when questioned under oath, each witness supporting the rescheduling of marijuana "admitted he was basing his opinion on anecdotal evidence, on stories he heard from patients, and on his impressions about the drug." The appeals court agreed with the FDA that "only rigorous scientific proof can satisfy" the requirements needed to change marijuana's rating and let the FDA's position stand.

THE MEDICAL USE OF MARIJUANA—A POLITICAL ISSUE OR A SCIENTIFIC ISSUE?

In 1997 the White House Office of National Drug Control Policy (ONDCP) made an effort to take the issue out of the political arena and place it in the scientific arena. The ONDCP asked the Institute of Medicine (IOM), a private, nonprofit organization that provides health-policy advice to Congress, to review the scientific evidence on the potential health benefits and risks of marijuana. Following an eighteen-month study, the investigators concluded that "the future of cannabinoid drugs lies not in smoked marijuana, but in chemically defined drugsthatacton … humanphysiology" (Institute of Medicine, "Marijuana and Medicine: Assessing the Science Base," Washington, DC: National Academy Press, 1999). Rigorous clinical trials, along with the development of new delivery mechanisms for the drug, were among the recommendations of the IOM's report.

Yet the debate continued in the political arena. By the late 1990s voters in nine states—Alaska, Arizona, California, Colorado, Hawaii, Maine, Nevada, Oregon, and Washington—had approved initiatives intended to make marijuana legal for medical purposes. However, the initiatives were ineffective. The federal government threatened to prosecute doctors who wrote prescriptions for marijuana. In 1997 a group of doctors sued to prevent the federal government from revoking doctors' registrations, and a federal judge permanently enjoined the federal government from doing so in September 2000.

Patients, though, found it increasingly difficult to obtain the drug, especially since the federal government started closing down "buyers' clubs," or organizations that distribute medical marijuana to seriously ill patients who wouldn't be able to obtain it otherwise. Debate continued as federal prosecutors went up against the Oakland Cannabis Buyers Cooperative, a nonprofit organization that provides marijuana to doctor-approved patients. Though its operations were legal under California law, the federal government ordered an injunction against its operation. A new defense, that of "medical necessity," came out of the legal wrangling, and the Ninth Circuit Court of Appeals upheld the defense. But in 2001 the Supreme Court ruled that there is no "medical necessity" exception to drug laws since Schedule I states there is "no currently accepted medical use in treatment in the United States" for marijuana. This ruling, though it did not overrule state laws, did allow federal prosecutors to continue enforcing federal drug laws.

Hashish

Hashish is made from the THC-rich resinous material of the cannabis plant. This resin is collected, dried, and compressed into a variety of forms, including balls, cakes, and sticks. Pieces are then broken off and smoked. Most hashish comes from the Middle East, North Africa, Pakistan, and Afghanistan. According to the DEA, the THC content of hashish in the United States hovered around 6% during the 1990s. Demand in this country is limited.

Hash Oil

Despite the name, hash oil is not directly related to hashish. It is produced by extracting the cannabinoids from the cannabis plant with a solvent. The color and odor of hash oil depend on the solvent used. Most recently, seized hash oil has ranged from amber to dark brown with about 15% THC. In terms of effect, a drop or two of hash oil on a cigarette is equal to a single joint of marijuana.

ANABOLIC STEROIDS

Anabolic steroids are drugs derived from the male sex hormone testosterone. They are used illegally by some athletes, including weight lifters, bodybuilders, long-distance runners, cyclists, and others who believe that these drugs can give them a competitive advantage or improve their physical appearance. When used in combination with exercise training and a high-protein diet, anabolic steroids can lead to increased size and strength of muscles, improved endurance, and shorter recovery time between workouts.

Steroids are taken orally or by intramuscular injection. Most are smuggled into the United States and sold at gyms and competitions or by mail-order companies. The most commonly used steroids include boldenone (Equipoise), ethylestrenol (Maxibolin), fluoxymesterone (Halotestin), methandriol, methandrostenolone (Dianabol), methyltestosterone, nandrolone (Durabolin, Deca-Durabolin), oxandrolone (Anavar), oxymetholone (Anadrol), stanozolol (Winstrol), testosterone, and trenbolone (Finajet).

Steroid use was once considered a problem limited to professional athletes, but the Centers for Disease Control and Prevention reported in 2004 that 5 to 12% of male high school students and 1% of female students use steroids by the time they are seniors. Concerns about the drug led Congress, in 1991, to place anabolic steroids into Schedule III of the Controlled Substances Act.

Because concern about anabolic steroids is relatively recent, the adverse effects of large doses are not well established. Nonetheless, there is growing evidence of serious health problems, including cardiovascular damage, liver damage, and harm to reproductive organs. The Department of Justice and the DEA's Diversion Control Program lists the effects of steroids on its Web site (http://www.deadiversion.usdoj.gov/pubs/brochures/steroids/hidden/). Physical side effects include elevated blood pressure and cholesterol levels, severe acne, premature balding, reduced sexual desire, and atrophying of the testicles. Males may develop breasts, while females may experience a deepening of the voice, increased body-hair growth, fewer menstrual cycles, and diminished breast size. Some of these effects can be irreversible. In adolescents, bone development may stop, causing stunted growth. Some users become violently aggressive.

By the early 2000s, some professional sports agencies had begun to acknowledge that widespread steroid use was taking place in their ranks. In 2005 Major League Baseball initiated regular testing of players for steroid use.