drugs on the market

For centuries, recreational and medicinal drugs have evolved and adapted to the times. The invention of morphine’s hypodermic syringe in the mid-19th century helped as a pain reliever for soldiers in the American Civil War. LSD was widely distributed among health professionals in the early 1950s then linked heavily to counterculture music of the ’60s. Crack cocaine, a cheaper version of powered cocaine, became easily accessible and prevalent in working-class and low-income neighborhoods, further marginalizing communities from each other and creating a fervor of a war on drugs in the U.S.

Today, popular drugs include fentanyl and Ozempic - for differing reasons, but similar to the fact that they’ve become a byproduct of our current decade. And though recreational drugs such as marijuana and alcohol have been in existence for many years, their popularity continues – mainly due to their acceptance in current social and cultural norms. Though Hawaii’s current marijuana law only allows its usage for medicinal purposes, those who possess marijuana will not be prosecuted for possessing certain small amounts.     

Jeremy Roberts, M.D., of Advanced Psychiatric Therapeutics in Honolulu, helped explain prescription and recreational drugs used in Hawaii and signs of abuse to watch for.

Fentanyl

What is fentanyl and how did it become so popular?
When the medical community over-prescribed opiates in the 2000s, primarily to help manage pain, a population of opiate dependence was created and started to grow. Many looked to street sources, where a wave of cheap, easily synthesized fentanyl came on the market. As fentanyl is particularly potent but has a very short half-life (effects start and end very quickly), dealers can cut their normal opiate with fentanyl to provide what is perceived by the opiate use disorder patient as effective, but costs the dealer less than the normal, unadulterated opiate would cost. The problem is, a small miscalculation can quickly lead to an overdose for the consumer.  

What are the major pros and cons of fentanyl?
In the outpatient setting, it is almost all cons, with very few pros. In a clinical setting, fentanyl kicks in very quickly to alleviate pain. Though fentanyl can be very effective in the operating room, its short half-life makes almost any outpatient application largely useless. Fentanyl patches transmit fentanyl in a very controlled fashion through the skin for up to three days and are sometimes used for chronic pain. This route, however, is increasingly controversial, except in very specific circumstances, in light of the opiate epidemic.

What can people in Hawaii do to prevent more people from dying of fentanyl overdoses?  
If I had a whiff of concern about problematic opiate use, I would immediately obtain a naloxone nasal spray (available over the counter or on Amazon). 

If you see a loved one experiencing an overdose, there’s not much you can do. The use at first causes the patient to relax, then look like they’re sleeping, then they become increasingly unresponsive or very intermittently responsive. Finally, their breathing slows down or become erratic, then progresses into total cessation of (or inadequate) breathing. That’s the part that kills them. 

You can call 911. You can give them support breathing if you’re trained in it. Those help a little. But naloxone almost immediately reverses the opiate, it’s life-saving. But you have to have it available immediately.

Ozempic

What is Ozempic and its side effects?
Ozempic is a medication that helps lower blood sugar in people with type 2 diabetes or hyperglycemia. According to the Centers for Disease Control and Prevention, although Ozempic is designed for diabetes management, it has become a popular off-label option for weight management.

Ozempic may cause serious side effects including inflammation of your pancreas, changes in vision, and kidney problems. Wegovy contains the same active ingredient as Ozempic (semaglutide) and is designed specifically for weight loss. Tip from a doctor: Be careful about shopping for weight loss drugs online and always work with your doctor and a licensed pharmacy. Some weight loss medications, such as compounded Ozempic, have not been approved by the Food and Drug Administration for quality and safety and can be dangerous.

How do you feel about patients using it as a weight-loss supplement?
If we have options that can effectively treat obesity with fewer risks than the obesity itself, we should use them. In patients who take Ozempic only for diabetes, which is of course, perfectly acceptable. If it also helps them lose weight in the process, that’s awesome.

I have several medications I recommend that might have side effects that assist other conditions. To limit a medication to only a single-minded purpose, and not recognize the broader context of the patient, is to overlook half of the medicine.

Recreational drugs
What are some of the recreational drugs that have been used here in Hawaii and what are their pros and cons?

People may be surprised to hear that the socially acceptable drugs are the largest problems. For every methamphetamine use disorder patient I see, I see five to 10 nicotine, alcohol, or marijuana use disorder patients. 

Their use is given a pass, both by society and themselves, as they can rationalize that this is “normal.” But if you find yourself needing the substance on a daily basis, if you’re spending time and money that you don’t have to obtain it, or if you find that not having it is troublesome for you, I would encourage some introspection.

Psilocybin (the active chemical in “magic mushrooms”) is also popular as they grow natively in Hawaii. When not used for their hallucinogenic properties, I’ve seen magic mushrooms treat depression. Its unregulated use, however, has several drawbacks such as dose consistency, as one mushroom may have a lot more psilocybin per gram than another.

More problematic is that during the time of use, the patient can be distinctly vulnerable and not able to make reasonable decisions or protect themselves. This can be minimized with supervision, but often an addict is attempting to avoid others knowing about the use, leading to a situation where they have no supervision during this vulnerable time.

Ketamine and esketamine have also recently become popular in Hawaii. These are anesthetic and dissociative agents that can cause prominent sedation, but can be misused in a recreational manner. Ultimately, the largest danger from ketamine is the same as psilocybin; unsupervised use can lead to unexpectedly dangerous situations.

Actor Matthew Perry died of a ketamine overdose. He was using very high doses of ketamine that resulted in him not being alert enough to simply sit up as he drowned in his hot tub. 

In general, Dr. Roberts says signs of drug abuse may or may not be obvious to the patients themselves so it’s vital to remain connected with loved ones and humble enough to receive feedback from them. The initial phases of addiction aren’t as obvious to outsiders (such as increasing use, cravings, or being unable to cut down). The more noticeable symptoms include difficulties at work, home, or school; engaging in dangerous situations as a result of use; or developing tolerance or withdrawal.

Every person and case is different so it’s important to reach out to your PCP if you have any questions or concerns. 

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