Energy Drinks: What’s the Big Deal?

The sons of Red Bull are sporting record concentrations of caffeine.

Are energy drinks capable of pushing some people into caffeine-induced psychotic states? Some medical researchers think so, under the right set of conditions.

Red Bull, for all its iconic ferocity, is pretty tame, weighing in at approximately half a cup of coffee. Drinks like Monster Energy and Full Throttle push it up to 100-150, or the equivalent of a full cuppa joe, according to USDA figures at Talk About Coffee. That doesn’t sound so bad—unless you’re ten years old. A little caffeine might put you on task, but an overdose can leave you scattered and anxious—or worse. If you cut your teeth on Coke and Pepsi, then two or three energy drinks can deliver an order-of-magnitude overdose by comparison.

Readers are entitled to ask: Are you serious? Can’t we just ignore the inevitable view-this-with-alarm development in normal kid culture, and move on? 

My interest began when I ran across a 2009 case report in CNS Spectrums, describing an apparent example of “caffeine-induced delusions and paranoia” in a very heavy coffee drinking farmer. “Convinced of a plot against him,” the psychologists write, “he installed surveillance cameras in his house and on his farm…. He became so preoccupied with the alleged plot that he neglected the business of the farm…. and he had his children taken from him because of unsanitary living conditions.”

The patient was not known to be a drinker, reporting less than a case of beer annually. He had shown no prior history of psychotic behaviors. But for the past seven years, he had been consuming about 36 cups of coffee per day, according to his account. Take that number of cups times 125 milligrams, let’s say, for a daily total of 4500 milligrams. At that level, he should be suffering from panic and anxiety disorders, according to caffeine toxicity reports, and he would be advised to call the Poison Control Center. And that certainly seems to have been the case. “At presentation,” the authors write, “the patient reported drinking 1 gallon of coffee/day.”

On the one hand, the idea of caffeine causing a state resembling chronic psychosis is the stuff of sitcoms. On the other hand, metabolisms do vary, and the precise manner in which coffee stimulates adenosine receptors can lead to anxiety, aggression, agitation, and other conditions. Could caffeine, in an aberrant metabolism, break over into full-blown psychosis? At the Caffeine Web, where psychiatrists and toxicologists duke it out over all things caffeinated, Sidney Kay of the Institute of Legal Medicine writes: “Coffee overindulgence is overlooked many times because the bizarre symptoms may resemble and masquerade as an organic or mental disease.” Symptoms, he explains, can include "restlessness, silliness, elation, euphoria, confusion, disorientation, excitation, and even violent behavior with wild, manic screaming, kicking and biting, progressing to semi-stupor.”

That doesn’t sound so good. In “Energy drinks: What is all the hype?” Mandy Rath examines the question in a recent issue of the Journal of the American Academy of Health Practitioners.

Selling energy drinks to kids from 6 to 19 years old is a $3.5 billion annual industry,Rath asserts. And while “most energy drinks consumed in moderation do not pose a huge health risk,” more and more youngsters are putting away higher and higher doses of caffeine. At the level of several cans of Coke, or a few cups of strong coffee or, an energy drink or three, students can expect to experience improved reaction times, increased aerobic endurance, and less sleepiness behind the wheel. Most people can handle up to 300 mg of caffeine in a concentrated blast. Certainly a better bargain, overall, than three or four beers.

But first of all, you don’t need high-priced, caffeine-packed superdrinks to achieve that effect. A milligram of caffeine is a milligram of caffeine. But wait, what about the nifty additives in Full Throttle and Monster and Rockstar? The taurine and… stuff. Taurine is an amino acid found in lots of foods. Good for you in the abstract. Manufacturers also commonly add sugar (excess calories), ginseng (at very low levels), and bitter orange (structurally similar to norepinephrine). However, the truly interesting addition is guarana, a botanical product from South America. When guarana breaks down, it’s principal byproduct is, yes, caffeine. Guarana seeds contain twice the caffeine found in coffee beans. Three to five grams of guarana provide 250 mg of caffeine. Energy drink manufacturers don’t add that caffeine to the total on the label because—oh wait, that’s right, because makers of energy drinks, unlike makers of soft drinks, don’t have to print the amount of caffeine as dietary information. And on an ounce-for-pound basis, kids are getting a lot more caffeine with the new drinks than the older, labeled ones.

All of this increases the chances of caffeine intoxication. Rath writes that researchers have identified caffeine-related increases among children in hypertension, insomnia, motor tics, irritability, and headaches. Chronic caffeine intoxication results in “anxiety, emotional disturbances, and chronic abdominal pain.” Not to mention cardiac arrhythmia, seizures, and mania.

So what have we learned, kids? Energy drinks are safe—if you don’t guzzle several of them in a row, or substitute them for dinner, or have diabetes, or an ulcer, or happen to be pregnant, or are suffering from heart disease or hypertension. And if you do OD on high-caffeine drinks, it will not be pleasant: Severe palpitations, panic, mania, muscle spasms, etc. Somebody might even want to take you to the emergency room. Coaches and teachers need to keep a better eye out for caffeine intoxication.

Note: There is a “caffeine calculator” available at the Caffeine Awareness website, designed to determined whether you are a coffee addict. I can by no means swear to its scientific accuracy, but, based on my own, distinctly non-young person daily intake, the test told me that my consumption was likely to manifest itself as “high irritability, moodiness & personality disorders.” Can I blame it all on those endless cokes we had as kids? Growing up in the Baby Boom suburbs, we all drank carbonated caffeine beverages instead of water. Nothing much has changed except the caffeine levels.

Rath, M. (2012). Energy drinks: What is all the hype? The dangers of energy drink consumption Journal of the American Academy of Nurse Practitioners, 24 (2), 70-76 DOI: 10.1111/j.1745-7599.2011.00689.x

Graphics Credit: http://urlybits.com/

A Look at the Recent Study of Cannabis and Multiple Sclerosis

Smoked marijuana reduced spasticity in a small trial of MS patients.

The leading wedge of the medical marijuana movement has traditionally been centered on pot as medicine for the effects of chemotherapy, for the treatment of glaucoma, and for certain kinds of neuropathic pain. From there, the evidence for conditions treatable with marijuana quickly becomes either anecdotal or based on limited studies. But pharmacologists have always been intrigued by the notion of treating certain neurologic conditions with cannabis. Sativex, which is sprayed under the tongue as a cannabis mist, has been approved for use against multiple sclerosis, or MS, in Canada, the UK, and some European countries. (In the U.S., parent company GW Pharma is seeking FDA approval for the use of Sativex to treat cancer pain).

There is accumulating evidence that cannabinoid receptors may be involved in controlling spasticity, and that anandamide, the brain’s endogenous form of cannabis, is a specific antispasticity agent.

Additional evidence that researchers may be on to something appeared recently in the Canadian Medical Association Journal. Dr. Jody Corey-Bloom and coworkers at the University of California in San Diego conducted a small, placebo-controlled trial with adult patients suffering from poorly controlled spasticity. Thirty participants were randomly divided into two groups. Those in the first group were given a daily joint, and those in the second group received “identical placebo cigarettes.” After three days, the investigators found that smoked marijuana resulted in a reduction in treatment-resistant spasticity, compared to placebo.

Clearly, it’s hard for a study of this sort to be truly blind: Participants, one presumes, had little trouble distinguishing the medicine from the placebo. And in fact, an appendix to the study shows this to be true: “Seventeen participants correctly guessed their treatment phase for all six visits… For the remaining participants, cannabis was correctly guessed on 33/35 visits.” This raises the question of various kinds of self-selection bias and expectancy effects, and the study authors themselves write that the results “might not be generalizable to patients who are cannabis-naïve.” On the other hand, cannabis-naïve patients were in the minority. The average age of the participants was 50, and fully 80% of them admitted to previous “recreational experience” with cannabis. (I don’t have a good Baby Boomer joke for the occasion, but if I did, this is where it would go).

I asked Dr. Corey-Bloom about this potential problem in an email exchange: “The primary outcome measure was the Ashworth Spasticity Scale, which is an objective measure, carried out by an independent rater,” she wrote. “Their job was just to come in and feel the tone around each joint (elbow, hip, knee), rate it, and leave.  That's why we think it was so important to have an objective measure, rather than just self-report.”

With all this in mind, the study found that “smoking cannabis reduced patient scores on the modified Ashworth scale by an average of 2.74 points.” The authors conclude: “We saw a beneficial effect of smoked cannabis on treatment-resistant spasticity and pain associated with multiple sclerosis among our participants.”

Other studies have found similar declines in spasticity from cannabinoids, but have tended not to use marijuana in smokable form.

Corey-Bloom, J., Wolfson, T., Gamst, A., Jin, S., Marcotte, T., Bentley, H., & Gouaux, B. (2012). Smoked cannabis for spasticity in multiple sclerosis: a randomized, placebo-controlled trial Canadian Medical Association Journal DOI: 10.1503/cmaj.110837

Photo Credit: http://blog.amsvans.com/

Marijuana Can Make You Vomit, and Other Stories

Short subjects, various.

First, a recap of an earlier story, and a very strange story at that. Cannabinoid hyperemesis, as it's known, was not documented in the medical literature until 2004, and was first brought to wider attention earlier this year by the biomedical researcher who blogs as Drugmonkey. Episodes of serial vomiting appear to be a very rare side effect of regular marijuana use. Posting on his eponymous blog, Drugmonkey documented cases of hyperemesis that had been reported in Australia and New Zealand, as well as Omaha and Boston in the U.S.

As Drugmonkey reported, “patients had discovered on their own that taking a hot bath or shower alleviated their symptoms. So afflicted individuals were taking multiple hot showers or baths per day to obtain symptom relief.”

A year ago, I published a post on this topic, titled "Marijuana, Vomiting, and Hot Baths." Sure enough, a number of people left comments about their own experiences with this unusual and unpleasant effect. Recently, one of my commenters caught drugmonkey’s eye, and he noted it in his new blog post on the phenomenon:

“Dirk Hanson's post on cannabis hyperemesis garnered another pertinent user:

Anonymous said...
My son suffers from this cannabinoid hyperemesis. At this moment he is here at my home on the couch suffering. I have been up with him for 3 days with the vomiting and hot baths. He says this time its over for good. This is our third bout. The first two time we went to ER, they put him on a drip to hydrate him, and gave him some pain medicine and nausea medicine. After a few hours he went home and recovered. This time we went to Urgent Care, put him on a drip, pain med, Benadryl, and Zofran….

Drugmonkey writes: “I reviewed several case reports back in 2010.... and there was considerable skepticism that the case report data was convincing. So I thought I'd do a PubMed search for cannabis hyperemesis and see if any additional case reports have been published…. One in particular struck my eye. Simonetto and colleagues (2012) performed a records review at the Mayo Clinic. They found 98 cases of unexplained, cyclic vomiting which appeared to match the cannabis hyperemesis profile out of 1571 patients with unexplained vomiting and at least some record of prior cannabis use… this is typical of relatively rare and inexplicable health phenomena. The Case Reports originally trickle out... this makes the medical establishment more aware and so they may reconsider their prior stance vis a vis so-called "psychogenic" causes. A few more doctors may obtain a much better cannabis use history then they otherwise would have done. More cases turn up. More Case Reports are published. etc. It's a recursive process. “
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In a story I think of as vaguely related, in the sense that it is a rare drug phenomenon unrecognized by the public, I recently wrote an article  for The Dana Foundation on the subject of “Smoking’s Ties to Schizophrenia.” In addition, check out a story about plans by the Air Force to make their hospitals and clinics smoke-free HERE. In brief: Smoke-free clinics pose major problems for heavy smokers with mental health disorders.
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Speaking of hospitals, Michelle Andrews reports in Kaiser Health News that about half of the patients undergoing treatment in hospital emergency rooms are under the influence of booze. Alcohol screening and counseling can be effective in this context—but there’s a catch. “Regardless of state law, self-insured companies that pay their employee’s health care costs directly can refuse to cover employees for alcohol-related claims.”

Even though the National association of Insurance Commissioners does not recommend it, dozens of states have passed laws allowing health insurers to deny payment for a patient’s injuries if they were incurred while he or she was under the influence of alcohol. About as many states have passed laws prohibiting such exclusions due to alcohol. The result is one big mess, and confusion reigns. As a professor of health law put it: “There’s no reason to think that insurers, eager to hold down costs, wouldn’t continue” to deny payment for alcohol-related injuries.
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And finally, some news about Chantix (varenicline), the drug both patients and doctors love to hate. It often works very well as an anti-craving medication for smoking cessation. But it can also, in some cases, present patients with a bewildering array of psychological side effects, including rare cases of suicidal ideation. A new study  by researchers at the Ernest Gallo Clinic and Research Center at the University of California, San Francisco, suggests that Chantix may have application in the treatment of alcoholism as well. Participants in the study reduced the average number of drinker per week on Chantix, compared to placebo. The study was funded by the National Institutes of Health and the State of California. Pfizer, the company that markets Chantix, did not fund or participate in the study.

Graphics Credit: http://teesdiary.files.wordpress.com/

What It Means to Say Alcoholism is Genetic

One woman’s journal.

From Insanity to Serenity, by Tommi Lloyd

Excerpts:

"I was born in 1963 in Toronto, Canada, to a family struggling long before I arrived. My dad was an alcoholic, born in Wales in 1921. His father and namesake was also an alcoholic who died at age 28…. My oldest sibling and only brother, Harry, entered a treatment centre at age 36 and has been sober for more than 20 years…. My Uncle Griff died from alcoholism when I was 10 years old…. There were no reprieves by which we spent a day or two in a sober environment. Dad drank from morning until night…. Christmas, Thanksgiving, and Easter—these were some of the worst days of the year…. Santa started leaving a carton of cigarettes next to my stocking at Christmas and I thought it was great.

"I yearned for some quality time before his drinking took center stage for the day… he drank from the minute he got up to the minute he passed out. At the height of his addiction, he was drinking more than 40 ounces of vodka a day…. There were many times when I would walk into the bedroom and see him guzzling the vodka straight from the bottle. It made me feel physical ill and utterly helpless.

"I too, am an alcoholic. In addition to alcohol, my teenage love of marijuana turned into a 30-year affair…. I have two nephews who are addicted to marijuana…. Rather than being sloppy drunks, my nephews opted for the mellow alternative that’s not addictive, (so we like to think) and you can pay for your habit by selling it to your friends.

"By age 11 I tried drinking for the first time…. I recall Susie telling us we could try drinking, but it had to be done quickly so as not to get caught. We poured some very strong rum and cokes and I guzzled mine down by holding my nose with my free hand…. As soon as I lay down on my bed the room started spinning and it wasn’t long before I was throwing up. Mom fussed over me, concluding I had the flu and I recall feeling both happy and guilty at the same time. I loved the attention but felt badly for the cause of my illness. I didn’t drink again for a few years….

"There is nothing more validating for me as a mother than to know I’m an inspiration to my children. I could not have asked for a better gift. This is what sobriety and a renewed spiritual life has brought my children and me…. Intellectually, I recognize how my childhood experiences and the disease of alcoholism molded a lot of my behavior and have been the root of much of my struggle with self-esteem. But self-knowledge does not change our circumstances, action does."

Gateway to Absurdity

State law criminalizes “gateway sexual activity.”

It’s the gateway to hell and perdition, that’s what it is. It doesn’t necessarily lead to drugs but it will drag you in the direction of Ess Eee Exx. And while sex is probably not addictive in the traditional sense, it is always and inevitably very bad when unaccompanied by marriage and the procreative urge.

Like anthropology’s search for the “missing link,” or the physicist’s search for a “unified field theory,” psychologists and social workers have spent decades hunting for the mythical gateway drug. This is the drug that, when used regularly, will head you reliably down the path of full-blown addiction. The findings of addiction medicine now make the identification of any kind of universal gateway drug an antique pursuit. Every addict finds his or her own gateway, and pushes through. If any drugs qualify as gateway drugs in a broad sense, it would have to be alcohol and tobacco, simply on the basis of ready availability.

But a gateway for full-blown recreational teenage sex—did you ever think about that? One might have thought the legislators would answer, yes, it’s called puberty, and move on. But no. The Tennessee legislature, led by Rep. Jim Gotto (R), managed to push through a bill  “allowing parents to sue teachers and other outside parties for ‘promoting or condoning gateway sexual activity’ by students.”

Interestingly, the bill apparently fails to define such activity in concrete terms. Evidently, Rep. Gotto has attempted to outlaw “first base.” Or, as TPMMuckraker put it, “other things.” Gateway sexual activity is defined, according to what I shall dub the bill’s "money" sentence, “sexual conduct encouraging an individual to engage in a non-abstinent behavior.” Okay, then. Earnest glances, hair tossing, hand holding—all potentially actionable, should any sex ed teachers be caught “promoting” such activities.

And not without reason: According to data released last month by the National Center for Health Statistics, the states with the highest teen birth rate in 2010 include Tennessee, which ranked 10th worst with 43.2 births per 1,000 teenage girls. And according to a 2009 risk behavior study in Memphis City, 61 percent of high school students have had sex, along with 27 percent of middle school students, putting Memphis City, and by extension Tennessee, considerably above the national average.

Apparently, the real target here is Planned Parenthood, which has been known to provide sex education information in Tennessee schools, and which would be facing fines and penalties under the new law. The bill calls for abstinence-only instruction.

Photo Credit: http://cbcpforlife.com/?p=4277

Review: Memoirs of an Addicted Brain

“I’m a drug addict turned neuroscientist.”

What’s it like to swallow 400 milligrams of dextromethorphan hydrobromide, better known as Romilar cough syrup? “Flashes of perception go by like clumps of scenery on either side, while you float along with the slow, irresistible momentum of a dream.” Marc Lewis, a former addict, now a practicing neuroscientist, further muses: “But what was Romilar? It sounded like an ancient kingdom. Would this dark elixir take me to some faraway place? Would it take me into another land? Would it be hard to come back?”

In Memoirs of an Addicted Brain: A Neuroscientist Examines his Former Life on Drugs, Dr. Marc Lewis follows his description of his gateway Romilar drug experience with the neurological basics of the matter: “The problem is that the NMDA receptors in my brain are now clogged with dextromethorphan molecules! The glutamate isn’t getting through. The receptor neurons aren’t firing, or they’re not firing fast enough…. Drugs like DM, ketamine, PCP, angel dust, and those most damaging of substances, glue and gasoline, are called dissociatives, because they do exactly what drugs are supposed to do: they dissociate feeling from reality, meaning from sense—and that’s all they do.”

Speaking of the self-reinforcing cycle “through which calamities of the mind arise from vulnerabilities of the brain,” Lewis argues that dissociatives only produce an absence. As a friend of his puts it with regard to another popular dissociative, “Nitrous oxide doesn’t give you consciousness. It takes it away.” And then, the friend adds: “Just bonk yourself on the head with a baseball bat if you want to lose consciousness.”

Lewis ultimately turns to opioids. “The emotional circuitry of the ventral striatum seems to derive its power from an intimate discourse between opioid liking and dopamine wanting.” In the end, this partnership does more than produce pleasure. It also, Lewis points out, “gets us to work for things.” And by doing that, addictive drugs demonstrate “the fundamental chemistry of learning which really means learning what feels good and how to get more of it. Yet there’s a downside: the slippery slope, the repetition compulsion, that constitutes addiction. In other words, addiction may be a form of learning gone bad. For me, this neurochemical sleight of hand promises much more pain than pleasure in the years to come.”

Lewis does a good job of capturing the feeling of existential despair brought on by uncontrolled addiction: “Contemptible. That’s what I was. Unbelievably stupid, unbelievably irresponsible: selfish, selfish, selfish! But that wasn’t quite it. What described me, what this inner voice accused me of, wasn’t exactly selfish, not exactly weak, but some meridian of self-blame that included both, and also, dirty, disgusting… maybe just BAD.”

How did heroin feel? “I feel relief from that pervasive hiss of wrongness. Every emotional wound, every bruise, every ache in my psyche, the background noise of angst itself, is soaked with a balm of unbelievable potency. There is a ringing stillness. The sense of impending harm, of danger, of attack, both from within and without, is washed away.”

And Lewis provides a memorable summation of the reward system, as dopamine streams from the ventral tegmental area to its targets, “the ventral striatum, where behavior is charged, focused, and released; the orbitofrontal cortex, where it infuses cells devoted to the value of this drug; and the amygdala, whose synapses provide a meeting place for the two most important components of associative memory, imagery and emotion.” In fact, “dopamine-powered desperation can change the brain forever, because its message of intense wanting narrows the field of synaptic change, focusing it like a powerful microscope on one particular reward. Whether in the service of food or heroin, love or gambling, dopamine forms a rut, a line of footprints in the neural flesh.”

And, of course, Lewis relapses, and eventually ends his addictive years in an amphetamine-induced psychosis, committing serial burglaries to fund his habit. “You’d think that getting busted, put on probation, kicked out of graduate school, and enduring a kind of infamy that was agonizing to experience and difficult to hide—all of that, an the need to start life over again—would be enough to get me to stop. It wasn’t.”

Not then, anyway. But Lewis has been clean now for 30 years. “Nobody likes an addict,” he writes. “Not even other addicts.”

If drugs are such feel-good engines, what goes wrong? Something big. “Because when drugs (or booze, sex, or gambling) are nowhere to be found, when the horizon is empty of their promise, the humming motor of the orbitofrontal cortex sputters to a halt. Orbitofrontal cells go dormant and dopamine just stops. Like a religious fundamentalist, the addict’s brain has only two stable states: rapture and disinterest. Addictive drugs convert the brain to recognize only one face of God, to thrill to only one suitor.”  The addict’s world narrows. Dopamine becomes “specialized, stilted, inaccessible through the ordinary pleasures and pursuits of life, but gushing suddenly when anything associated with the drug comes into awareness…. I wish this were just an exercise in biological reductionism, or neuro-scientific chauvinism, but it’s not. It’s the way things really work.”

Photo Credit: http://ebookstore.sony.com/

What's in That X Pill, Ravers?

Ecstasy comes loaded with other drugs. 

 I'm not a huge fan of infographics, mostly because they tend to overpromise and are often marred by factual errors. But this one sticks to basics, and reminds kids that pure MDMA is not the play here. Familiar with dibenzylpiperazine? How about 5-MEO-DIPT? Good old methamphetamine you know—but do you want your Ecstasy, itself an amphetamine spinoff, springloaded with an extra dose of it? Scroll down for pictures of "dirty rolls."

 Via Recovery Connection
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