Emmalyn Pepper Clemmensen

A recent survey looking at drug use in American adolescents found that 5.4% of 8th graders, 9.8% of 10th graders, and 14.3% of 12th graders used illicit drugs other than marijuana.1 Additionally, they commonly abuse alcohol and tobacco.2 There are many reasons why teens begin to use different substances—including wanting to experiment, peer pressure, and stress—but continued use can lead to significant problems. Substance use may progress to a substance use disorder (SUD) when repeatedly abusing alcohol or drugs causes significant impairment in functioning—physically, socially, and at school, work, or home.3 Estimates state that approximately 1.5 million teenagers meet the criteria for an SUD, yet only 7% of them receive treatment.4 However, many treatment programs exist for teens, and some of these may include detox as the first treatment component. The main purpose of a detox program is to safely manage symptoms of withdrawal. Detox programs tend to be the first step in the recovery process and typically range from 3 to 5 days, though they could last longer for certain substances and significantly severe cases of physical dependence.5,6 Some detox programs incorporate a medical component that includes intensive medical monitoring while your body rids itself of the substances you have been abusing.5,6 Detox programs may also provide brief intensive counseling and prepare you for longer-term treatment options.6 What to Look For When looking for an effective detox program, there are several factors to consider, such as if medical services are offered (which is especially important if your teen has been using alcohol or benzodiazepines); if the program is able to handle dual diagnoses when mental health issues are also present; the thoroughness of the screening and assessment process; the use of evidence-based practices; the training of clinicians and staff members; and ethical standards. Medical Services Some detox programs offer medical services, in which they use medications to reduce the discomfort or danger associated with certain withdrawal symptoms. More medically based programs may also provide access to surgeons, neurologists, psychiatrists, anesthesiologists, and other specialized medical providers, depending on how severe the withdrawal symptoms are, or if co-occurring physical issues are present. If you are detoxing from alcohol, sedative-hypnotics, or opioids, hospitalization or some form of medical care may be necessary since withdrawal symptoms tend to be more severe and/or dangerous with these substances.7  Dual Diagnosis Treatment It is also important to consider whether or not a detox program can work with those who have dual diagnoses, which is having both a substance use disorder and a mental health disorder, such as depression or anxiety. This is important because the physical detoxification process tends to lead to challenging psychological symptoms, and substance abuse in general can exacerbate mental health issues.7 Detox treatment facilities should know how to handle situations where teens are on mental health medication and also need detox medications, since there could be harmful interactions. Also, withdrawal symptoms sometimes mimic symptoms of psychiatric conditions; a qualified teen detox facility will have experience monitoring and evaluating patients to make proper judgments regarding the course of treatment.7 Assessment and Screening The major components of assessment and screening within a detox program are evaluation, stabilization, and guidance into longer-term treatment programs.7,8 Evaluation includes testing for substances within the bloodstream and measuring the concentration of these substances. It also includes assessing your medical conditions, psychological concerns, and social situation to help you find the most appropriate level of treatment following detox. This step is key to forming your initial treatment plan.7 Stabilization involves the medical and psychosocial process of helping you through acute intoxication and withdrawal to achieve medical stability in a substance-free state, which may be done with or without medications. This part of the process may also include educating you about your role in treatment and recovery. Clinicians may try to get your family, friends, and others who are important to you involved in your care at this stage. Lastly, clinicians may assist in preparing you to enter long-term substance abuse treatment programs by emphasizing how important it is to follow through with your treatment plan and continuing treatment options. To effectively plan for these options, a comprehensive drug use history and in-depth assessment of your strengths and any weaknesses that need to be addressed may take place. Appropriate treatment planning considers factors such as: medical and mental health history, psychological development, risk of severe withdrawal symptoms, relationships with family members, relationships with friends and peers, academic performance, participation within the community, cultural and ethnic considerations, gender considerations, physical issues, transportation concerns, and legal involvement. Various screening instruments that may be used in this process include:5 The Substance Abuse Subtle Screening Inventory (SASSI). The Personal Experience Screening Questionnaire (PESQ). The Comprehensive Addiction Severity Index for Adolescents (CAS-I). The Global Assessment of Individual Needs (GAIN). Evidence-Based Practices It is also important for detox programs to use evidence-based treatment options to ensure best outcomes. These kinds of practices are those that have been studied and have research that supports their effectiveness. Research evidence combined with clinical expertise and client values lead to optimal treatment outcomes.9 Depending on the substance(s) you are detoxing from, there may be different evidence-based detox treatment methods available (e.g., medication management for opioid detox).  Training and Ethical Standards Because the detoxification process may include unpleasant and potentially dangerous physical symptoms, such as restlessness, agitation, anxiety, nausea, vomiting, loss of appetite, insomnia, intense dreaming, nightmares, hallucinations, delusions, or even seizures (e.g., the symptoms of alcohol withdrawal), it is important to work with providers who have proper training and can identify whether hospitalization or other forms of medical care are necessary.7 For this and other reasons, feeling comfortable with and trusting a program is very important. Working with clinicians and staff who are appropriately trained in addiction treatment; who have experience working with teens; who understand adolescent development; and who value your input may increase your comfort level with the programs you consider. Staff should also be able to recognize psychiatric issues, since many adolescents who have an SUD have a co-occurring mental health disorder.5 It is equally important that clinicians and staff are able to work effectively with families. Additionally, finding a program that has clearly stated and followed ethical standards is important in building trust with that program. Treatment Approaches Knowing which treatment approaches a detox program uses allows you to better assess if it will be a good fit for you. The following treatment approaches may be used briefly during detox programs but are especially effective when they are used over longer periods of time, after the initial detoxification period. The following sections include some of the most common treatment approaches.5,6,7 Medication Management Medications can help reduce certain withdrawal symptoms, assist in reestablishing typical brain function, and help decrease cravings. There are currently medications available for easing the symptoms of detox from opioids, tobacco, and alcohol, while medications for stimulants and cannabis are currently being researched and developed. Medication may also be needed for co-occurring disorders, such as depression, anxiety, and bipolar disorder. This treatment should be provided by a qualified medical clinician. Individual Therapy Cognitive behavioral therapy (CBT) is often the treatment modality provided, which primarily focuses on your thoughts and feelings and how they impact your behavior. Motivational Interviewing (MI) may also be used to help you find and strengthen your internal motivation to work toward making positive changes around your addiction. It may be effective in motivating you to engage in longer-term programs after completing detox too. It is important to remember that because detox programs are short-term, the techniques mentioned above will be used briefly to address current concerns and to assist with effective treatment planning. These techniques may be continued after you complete your detox program. Family Therapy During a detox program, family therapy may be brief and used to increase the effectiveness of treatment planning (e.g., gaining a more well-rounded picture of the patient through information shared by family members, friends, and others who are important to them). Family therapy may be continued after the detox program has ended and may focus on improving communication with other family members and cultivating decision-making skills, problem-solving skills, negotiation, and coping mechanisms for stress. Family therapy aims to foster support within the family environment. Multisystemic Therapy (MST) MST is a heavily researched family- and community-based intensive treatment that has proven to reduce drug use and criminal behavior. Education Educating adolescents about withdrawal symptoms and the dangers of intoxication and withdrawal may encourage them to get help, such as attending a detox program, when they notice such symptoms. Educating teens about the risks and consequences associated with substance use may also guide them toward making healthier decisions after they complete detox. A combination of these treatment approaches is often used. It is important to remember that detox programs tend to be the first step in the recovery process and that they are shorter-term programs that can prepare you for longer-term treatment options.6 Age-Specific Considerations Detox programs that are appropriate for adults may not be best suited for adolescents, since the 2 age groups have different psychological, developmental, and social needs. When considering a teen detox program, evaluate age-specific factors, such as:4,5 Family involvement, since parents’ involvement in their child’s treatment and recovery increases the likelihood of a successful treatment experience. Strategies to engage teens and assist them in recognizing the value of getting help for their problems. Hands-on techniques relevant to adolescents’ concerns and developmental stages (e.g., incorporating technology into treatment). Positive reinforcement. Whether the program is tailored to the needs of younger adolescents (12- to 15-year-olds) or older adolescents (16- to 18-year-olds). Sexual issues. Healthy coping mechanisms for stress, especially stress related to school and peers. Emotional regulation. The role friends and other peers have on a teen, and the influence they may have on substance use. Academic performance and how it may be impacted by substance use. Collaboration with teachers during detox. Case management to assist the teen with remembering and participating in appointments. Clinicians and other staff who are experienced in working with adolescents and who understand how to engage and motivate them. When working with adolescents, it is especially important to work as a team. Not only does the teen need to be included in their own treatment, but their parents or legal guardians do, as well, to have a well-rounded recovery experience. Everyone should be able to give input, which allows a more complete picture of the teen to emerge and, subsequently, tailored treatment planning. When everyone on the team works together, the teen may feel more supported, from the detoxification period through the transition to longer-term substance abuse treatment. Sources National Institute on Drug Abuse. (2016). Monitoring the Future Survey: High school and Youth Trends. National Institute on Drug Abuse. (2014). Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide: What Drugs Are Most Frequently Used by Adolescents? Substance Abuse and Mental Health Services Administration. (2015). Substance Use Disorders. Winters, K.C., Botzet, A.M., & Fahnhorst, T. (2011). Advances in Adolescent Substance Abuse Treatment. Current Psychiatry Reports, 13(5), 416–421. Brannigan, R., Falco, M., Dusenbury, L., & Hansen, W.B. (2004). Reducing Underage Drinking: A Collective Responsibility. Washington (DC): National Academies Press (US). National Institute on Drug Abuse. (2016). Treatment Approaches for Drug Addiction. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse Treatment: A Treatment Improvement Protocol TIP 45. National Institute on Drug Abuse. (2014). Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide: Principles of Adolescent Substance Use Disorder Treatment. Duke University Medical Center. (2017). What Is Evidence-Based Practice (EBP)? ...

The stimulant class of substances contains several drugs that increase energy, alertness, focus, heart rate, blood pressure, and breathing rate.1 The class itself encompasses both illicit stimulants, such as methamphetamine (meth) and cocaine, and legally prescribed medications (though these too may be abused illicitly). Some examples of prescription stimulants include Dexedrine, Adderall, Ritalin, and Concerta.2 Ecstasy, or MDMA, is a somewhat unique member of the stimulant class due to its entactogenic and mild hallucinogenic properties. According to the United States Drug Enforcement Administration (DEA), many stimulants, such as pharmaceutical methamphetamine, cocaine, Dexedrine, Adderall, and Ritalin, are Schedule II substances, while MDMA is classified as a Schedule I controlled substance.4 Their controlled status means that, despite legitimate medical uses, they have a high potential for abuse and use may result in dependence.4 Abusing stimulants can place significant stress on the heart, which increases the user’s risk of experiencing adverse consequences and even death.5 List of Popular Stimulants There are many different types of stimulants that are commonly used or abused. They may be taken alone or in combination with other psychoactive substances, such as alcohol or marijuana. Popular stimulants of abuse include:1,2,3,6 Dextroamphetamine (Dexedrine and Adderall) is a medication commonly prescribed for ADHD, although it may also be prescribed for narcolepsy. Methylphenidate (Ritalin and Concerta) is another medication commonly prescribed for ADHD and narcolepsy. Cocaine is predominantly obtained from the illicit market and has a long history of widespread abuse. When in powdered form it is most often snorted, but it can also be smoked or injected into the veins after being dissolved in water. Methamphetamine (meth) can be obtained in various forms, including both powder and pills. Crystal meth more frequently resembles pieces of glass or shiny blue-white rocks of various sizes.3 Meth may be taken orally, smoked, injected, or snorted. 3,4-methylenedioxy-methamphetamine (MDMA or Ecstasy) is an illegal substance that shares both chemical structural features and drug effects with both stimulants and some other hallucinogens. It is often encountered on the illicit market as a capsule or tablet, but may also be swallowed in liquid form, or snorted as a powder. Each one of the above-mentioned stimulants increases the user’s heart rate, blood pressure, and respiratory rate, thus increasing the risk of adverse cardiovascular effects. Why Do People Abuse Stimulants? Stimulant use can have some desirable, if ultimately dangerous, effects. For example, stimulant use may lead to feelings of pleasure, sexual arousal, increased confidence, and increased focus.3 It may also promote weight loss by decreasing appetite.5 When used therapeutically by those with ADHD, stimulant can increase motivation, cognition, learning, and memory. The allure of such effects helps explain why so many people abuse them in the absence of medical necessity, despite the risks of detrimental and even fatal consequences.7 Because stimulants increase focus and motivation and decrease the need for sleep, many students use prescription stimulants as study aids. Research has found that college students are more likely to use prescription stimulants than their non-college-attending peers, potentially due to the need to stay awake to study.8 Research has also shown that college students in particular are not only using prescription stimulants as study aids, but also to stay awake longer to drink and party more.8 Mixing stimulants and alcohol is particularly risky since stimulant effects may delay or mask the symptoms of increased alcohol intoxication. Therefore, when a person mixes a stimulant with alcohol, they may end up drinking more than they otherwise would because they were not able to read their body’s warning signs, which can increase the risk of alcohol poisoning.9 Mixing stimulants with other substances may also put extra stress on the cardiovascular system, leading to dangerously high blood pressure or irregular heart rhythms, which is already a major concern with stimulant use, alone.10 Cardiac Effects There are many negative effects associated with stimulant use, but concerns regarding their impact on cardiopulmonary systems are especially significant. Stimulants have been known to cause the following:5 Increased blood pressure Increased heart rate Increased respiration rate In excessive doses and long-term use, stimulants have been found to cause the following:5,6,13 Extremely rapid heartbeat Erratic heartbeat Chest pain Respiratory failure Congestive heart failure Cardiomyopathy (enlarged, weakened, inefficiently functioning heart muscle) Stroke Heart attack Furthermore, intravenous stimulant users have an increased risk of contracting bacterial endocarditis, an infection of the heart lining.13 Bacterial endocarditis, if left untreated, can damage heart valves, leading to an inability to effectively pump blood to the body. This can progress to congestive heart failure. Additionally, pieces of myocardial vegetation (bacterial overgrowth and resulting blood clotting and immune system deposition) located at the site of infection can break off and travel through the blood vessels to the extremities and vital organs, which can lead to embolic damage to the lungs, kidneys, spleen, brain, intestines, and liver.14 Other serious consequences of stimulant abuse can include malnourishment, dental problems, suicidal ideation or behaviors, psychotic features such as paranoia and delusions, cerebral hemorrhaging (bleeding into the brain), brain damage, coma, seizures, and death. MDMA abuse can result in kidney, liver, or heart failure. The abuse of stimulants in general is associated with risky sexual behaviors, which increases the risk of sexually transmitted diseases (STDs) and other communicable diseases, such as HIV and hepatitis.5 MDMA, in particular, elicits feelings of emotional warmth and trust, which could also put the user at risk of engaging in unsafe sexual practices.6 Due to these potentially serious consequences, it is important to get treatment if you or a loved one is struggling with stimulant use or any kind. Quitting Stimulant Abuse The sooner you quit abusing stimulants, the lower your risk of experiencing significant harmful, long-term mental and physical consequences, particularly to the heart. Damage to the heart can negatively impact many other organs as well, thus causing significant impairment and harm. Completing an initial detoxification period and engaging in comprehensive substance abuse treatment can help you achieve and maintain sobriety. Detoxification is the process by which the body rids itself of a substance.11 While the body eliminates the drug, withdrawal symptoms may occur. Stimulant withdrawal symptoms may include:12 Drug cravings. Hypersomnia (excessive sleepiness). Insomnia (inability to sleep or stay asleep). Irritability. Depression. Anxiety. Fatigue. Impaired concentration. Slowed movements and cognition. Paranoia. Some people may be more susceptible to cardiovascular complications during stimulant withdrawal than others. Studies have shown that patients who abuse alcohol and cocaine may experience persistent problems associated with the heart, such as irregular heart beat and heart attacks due to the production of a deadly chemical, called cocoethylene.12 Professional detox can help to mitigate possible cardiovascular complications and enhance your safety. There are several settings where this detoxification process may take place, including in a hospital, an inpatient setting, a physician’s office, or an outpatient setting. More information on them:12 Hospital: Medically monitored detoxification takes place in a hospital. Although stimulant withdrawal is not typically associated with medical complications, there are a few things to look out for. Seizures are a potential complication of stimulant abuse that may also occur during detoxification and should therefore be monitored. Depression and suicidal thoughts are other major concerns related to stimulant withdrawal that may require close supervision. Inpatient: Inpatient settings may or may not be medically monitored, but the patient receives around-the-clock support from professional staff members. The complications described above should also be considered in these settings. Physician’s Office: This setting is appropriate if someone has been taking prescription stimulants for an extended period of time and would like to quit them with a doctor’s assistance. The physician can create a gradual tapering schedule in which a person is slowly weaned off of the drug to minimize the chance of significant withdrawal issues. Outpatient: Outpatient detox is an appropriate setting for someone with relatively mild addiction issues who can’t commit to 24-hour detox treatment and wants to return home after scheduled meetings. All of the same withdrawal concerns described above should be regularly assessed for in outpatient settings. If depression and suicidal thoughts should arise, a step up to a more intensive level of care may be required. It is important to note that many stimulant detox programs are very short-term, typically lasting several days. While the detoxification process is an important part of the journey to stopping stimulant use, it is important to continue the journey with longer-term substance abuse treatment. Substance abuse treatment may include education about the risks and consequences associated with drug use, along with strategies regarding how to prevent relapse. It also includes addressing deeper, underlying issues that trigger substance use. Formal substance abuse treatment is offered in a number of settings and each program is likely to utilize a somewhat unique therapeutic approach. These treatment varieties include inpatient, outpatient, luxury, executive, holistic, and population-specific. Inpatient: Many inpatient programs take place in a residential setting in which you stay at the treatment location the entire duration of the program (which tend to be 30, 60, or 90 days long) and have the opportunity to engage in a variety of services including group counseling, individual therapy, family therapy, peer support meetings, and healthy social activities. Outpatient: Outpatient programs involve regular attendance of group therapy or individual counseling sessions led by substance abuse counselors. Like inpatient therapy, these sessions will focus on education about substance use and related consequences, and help those in recovery to recognize the underlying issues and triggers that lead to substance use. There may also be a peer support component to outpatient settings. Luxury: As a luxury variant of residential treatment, luxury programs offer upscale amenities, such as gourmet meals, massage therapy, and spas. Executive: Also an inpatient/residential option, executive programs cater to working professionals who don’t want to take the time off of work to enter rehab. They offer internet access and private workrooms. Holistic: Holistic approaches include looking at the person as a whole, including the mind, body, emotions, and spirit. Finding balance within all of these areas is important for holistic healing. Population-Specific: These treatment programs specialize in addressing the unique needs of special populations. They may include male-only, female-only, teens, veterans, or LGBT. Although they are not considered formal substance abuse treatment, many people find 12-step programs, such as Narcotics Anonymous (NA), to be helpful as an adjunct to formal treatment or as ongoing support after the recovery program has been completed. It is important to remember that even after you have completed substance abuse treatment, aftercare and ongoing support is key to preventing relapse. Having the support of others and knowing which resources you can use when you experience triggers and feel like using can help guide you to stay clean and sober in the long run, and thus prevent damage to the heart and other organs. Sources National Institute on Drug Abuse. (2016). Which classes of prescription drugs are commonly misused? National Institute on Drug Abuse. (2016). How Do Stimulants Affect the Brain and Body? Substance Abuse and Mental Health Services Administration. (2016). Stimulants. United States Drug Enforcement Administration. Drug Scheduling. Substance Abuse and Mental Health Services Administration. (1999). Treatment for Stimulant Use Disorders. (Treatment Improvement Protocol (TIP) Series, No. 33.) Chapter 2—How Stimulants Affect the Brain and Behavior. Rockville, MD: Center for Substance Abuse Treatment. National Institute on Drug Abuse. (2016). MDMA (Ecstasy/Molly). National Institute on Drug Abuse. (2016). Which Classes of Prescription Drugs Are Commonly Misused? Arria, A. M., & Wish, E. D. (2006). Nonmedical Use of Prescription Stimulants Among Students. Pediatric Annals, 35(8), 565-571. Egan, K. L., Reboussin, B. A., Blocker, J. N., Wolfson, M., & Sutfin, E. L. (2013). Simultaneous Use of Non-medical ADHD Prescription Stimulants and Alcohol Among Undergraduate Students. Drug and Alcohol Dependence, 131(0), 71-77. National Institute on Drug Abuse. (2016). Is It Safe to Use Stimulants with Other Medications? National Institute on Drug Abuse. (2016). Treatment Approaches for Drug Addiction. Schwart, B.G., Rezkalla, S., & Klonger, R.A. (2010). Cardiovascular Effects of Cocaine. Contemporary Reviews in Cardiovascular Medicine, 122: 2558-2569. Cabell, C.H., Abrutyn, E., & Karchmaer, A.W. (2003). Bacterial Endocarditis: The Disease, Treatment, and Prevention. Cardiology Patient Page, 107: 185-187. ...

While you may be aware of common, illegal drugs of abuse, such as heroin, cocaine, marijuana, and crystal meth, there are several lesser-known, but no less dangerous, contributors to the more recent landscape of drug abuse: synthetic drugs. Many people believe that these substances are safer alternatives to more well-known drugs, while in fact they pose serious physical, mental, and emotional risks to the user. Synthetic drugs are not regulated and can vary from batch to batch, resulting in unpredictable and dangerous effects. Additionally, manufacturing, possessing, using, and selling certain synthetic drugs carries serious financial and legal consequences. What Are Synthetic Drugs? Synthetic drugs are sometimes referred to as designer drugs or as new psychoactive substances (NPS). Some of the more popularly abused lab manufactured synthetics have effects that resemble those of marijuana or cocaine. Dealers sell these drugs over the internet or at convenience stores, gas stations, novelty stores, or tobacco/smoke shops. Manufacturers often packages these substances in shiny plastic bags with eye-catching logos.1 It is a common misconception that synthetic drugs are harmless; they are actually quite dangerous.2 Some of these substances, such as synthetic cathinones and synthetic cannabinoids, can in fact be more potent than their naturally occurring counterparts and, as a result, may have more powerful effects on the brain.2,3 Furthermore, because the exact chemical composition of many synthetic drugs is unknown and can change from batch to batch, using these substances may result in significantly different effects than you might be expecting.2 Illegal Synthetic Drugs Some synthetic drugs, such as bath salts and synthetic marijuana like Spice or K2, are shadily marketed and appear in packaging designed to obscure their origins and potential dangers. Some synthetic drugs are not yet illegal and this gray area exists because they have escaped FDA attention, or because their molecular formulations have not yet landed on a DEA Schedule. That being said, many synthetic or designer drugs are illegal and you may face serious consequences if you manufacture, use, possess, or sell such substances.2  The following are examples of illegal synthetic drugs: Mephedrone, 3,4 methylenedioxypyrovalerone (MDPV) and methylone. Synthetic Cathinones (Bath Salts): Bath salts are chemically related to cathinone, a stimulant found in the khat plant, and have effects somewhat similar to other stimulants such as methamphetamine and cocaine. These drugs are frequently encountered as a white or brown, crystal-like powder and can be swallowed, snorted, smoked, or injected. Bath salts increase energy and raise heart rate and blood pressure. They can also cause paranoia, hallucinations, nosebleeds, sweating, nausea, dehydration, panic attacks, extreme agitation, violent behavior, breakdown of skeletal muscle tissue, and kidney failure.3 Three substances commonly used to manufacture bath salts—methylone, mephedrone, and 3,4, methylenedioxypyrovalerone (MDPV)—are Schedule I controlled substances, meaning that they currently do not have any accepted medical use and have a high potential for abuse.13 Synthetic Marijuana: Synthetic marijuana is manufactured using substances known as synthetic cannabinoids. Synthetic cannabinoids are molecularly similar to the primary psychoactive compounds found in the marijuana plant. These drugs are sprayed on dried, shredded plant material to be smoked, or sold as a liquid that can be vaporized and inhaled in e-cigarettes or similar devices. When sprayed on plant material, synthetic marijuana can also be brewed as a tea. Some of the side effects of synthetic marijuana include delusions, extreme anxiety, confusion, paranoia, hallucinations, vomiting, violent behavior, suicidal thoughts, increased blood pressure, kidney damage, and seizures.2 Because it has no accepted medical value and has a high potential for abuse, synthetic marijuana is a Schedule I drug, making it illegal to sell, buy, or possess.2 Phencyclidine (PCP): PCP is a white crystal-like powder that has a bitter taste. It may also be dyed a variety of colors. Dealers often sell PCP in tablet, capsule, liquid, or powder form. Users take it by snorting it as powder, swallowing it in tablet or capsule form, or smoking it by applying the powder to a leafy substance. Some users also dip marijuana or tobacco cigarettes in liquid PCP and smoke them. PCP use is associated with compulsive behavior, violent behavior, delusions, paranoia, and suicidal thoughts. Long-term use of PCP may also lead to memory loss, impaired speech and cognition, depression, and weight loss. PCP was once used as a general anesthetic agent, but this practice was stopped because of serious side effects in patients emerging from surgery.6 It is now Schedule II substance, meaning that despite accepted medical use (in this case, limited use in veterinary medicine), there is a high potential for abuse, and use could potentially lead to severe psychological or physical dependence.4,5 Possession, distribution, or use of PCP for nonmedical reasons is illegal. D-Lysergic Acid Diethylamide (LSD): LSD is a clear or white odorless substance, and it is a very powerful perception-altering chemical.6 It can cause visual and auditory hallucinations, feelings of detachment from your environment and yourself, distortions in time and perception, and flashbacks.7 LSD is an illegal, Schedule I substance.4,7 3,4-Methylenedioxymethamphetamine (MDMA): MDMA, or ecstasy, is a substituted methamphetamine drug with both hallucinogenic and stimulant properties. It is sometimes referred to as an empathogen or entactogen, meaning that, in addition to altering mood and perception, it may increase empathy or create a stronger sense of connection among those using the drug. It can be swallowed in tablet, capsule, or liquid form, or it can be snorted in powder form. MDMA can increase heart rate and blood pressure, cause nausea, muscle cramping, teeth clenching, blurred vision, chills, and sweating, as well as impact the body’s ability to regulate temperature, which could potentially lead to liver, kidney, or heart failure.8 MDMA is an illegal, Schedule I substance.4 Ketamine: Ketamine’s primary use is as a surgical anesthetic for both humans and animals.6 In terms of illicit use, it is most frequently snorted as a powder or taken as a pill, but it can also be injected as a liquid.6 Ketamine is a Schedule III substance, meaning that it has a moderate to low potential for physical and psychological dependence.4 However, misuse of the drug, such as by using it without a prescription, not using it as prescribed, or selling it to someone, is illegal. Much of the ketamine that is sold illegally comes from veterinary offices.6 Again, using, possessing, or selling the substances above may result in significant consequences. Not only can they take a serious psychological and physical toll on the user, but they can give rise to serious legal problems, as most of them are either completely illegal or illegal without a prescription. Penalties for Possession Possessing such synthetic drugs can come with hefty legal fines and other consequences. The first offense for simple possession could come with a fine of more than $1,000 and up to 1 year of imprisonment.9 The second offense for simple possession could include a fine of more than $2,500 and 15 days to 2 years of imprisonment.9 The third offense for simple possession may come with a fine of greater than $5,000 and 90 days to 3 years of imprisonment.9 Penalties for illegal distribution of these drugs vary depending on the substance in question:9 Bath Salts: Bath salts carry a fine of up to $1 million and up to 20 years of imprisonment. Synthetic Marijuana: Synthetic marijuana carries a fine of up to $1 million and up to 20 years of imprisonment. PCP: Depending on the amount you are in possession of (with intent to distribute), PCP could carry $1 to $50 million in fines and up to 40 years of imprisonment. LSD: Depending on the amount you are in possession of, LSD could carry a $1 to $50 million fine and up to 40 years of imprisonment. MDMA: MDMA carries a fine of up to $5 million and up to 20 years of imprisonment. Ketamine: Ketamine has a potential consequence of up to $2.5 million in fines and up to 15 years of imprisonment. The above information is for first-time offenses with those particular substances. The second and third offenses carry even more significant financial and legal consequences.9 Court-Ordered Rehab Another potential outcome of getting arrested for possession is having to go to rehab. Substance abuse treatment can be legally mandated through a drug court or as a condition of probation or parole. Research suggests that those who are legally mandated to participate in addiction treatment programs have as good as or even better outcomes that those who are not mandated to attend such programs. Other studies indicate that legal pressure can increase treatment attendance and improve retention, both of which positively impact treatment outcomes.11 Such programs can also be a source of support for those who are re-entering society.12 This is an important factor because this process may cause significant stress for the offender (i.e. finding housing, finding employment, rebuilding relationships with family), which is a risk for relapse.12 However, having support and learning about healthy coping skills, all of which can be obtained through a substance use treatment program, can help reduce the risk of relapse and increase the chances of successful recovery. Therefore, court-ordered treatment is an effective intervention for those struggling with substance use and related legal concerns. If you or someone you care about struggles with synthetic drug abuse, don’t wait until you get arrested to attend treatment. There are plenty of recovery programs available that can help you get clean and sober and remain abstinent in the long run. Sources S. Department of Justice Drug Enforcement Administration: Diversion Control Division. (N.D.). About Synthetic Drugs. National Institute on Drug Abuse. (2015). Synthetic Cannabinoids. National Institute on Drug Abuse. (2016). Synthetic Cathinones (“Bath Salts”). United States Drug Enforcement Administration. (N.D.). Drug Scheduling. National Drug Intelligence Center. (2006). PCP Fast Facts. National Institute on Drug Abuse. (2016). Hallucinogens.  Substance Abuse and Mental Health Services Administration. (2015). Hallucinogens.  National Institute on Drug Abuse. (2016). MDMA (Ecstasy/Molly). Yeh, B.T. (2015). Drug Offenses: Maximum Fines and Terms of Imprisonment for Violation of the Federal Controlled Substances Act and Related Laws. National Institute on Drug Abuse. (2014). Principles of Drug Abuse Treatment for Criminal Justice Populations-A Research-Based Guide: Are All Drug Abusers in the Criminal Justice System Good Candidates for Treatment? National Institute on Drug Abuse. (2014). Principles of Drug Abuse Treatment for Criminal Justice Populations-A Research-Based Guide: Is Legally Mandated Treatment Effective? National Institute on Drug Abuse. (2014). Principles of Drug Abuse Treatment for Criminal Justice Populations-A Research-Based Guide: Are Relapse Risk Factors Different in Offender Populations? How Should Drug Abuse Treatment Deal with These Risk Factors? Drug Enforcement Administration. (n.d.). Drug Fact Sheet: Bath Salts or Designer Cathinones (Synthetic Stimulants). ...