Ecstasy and Other Club Drugs

The last two issues of Pulse Check addressed "club drugs" as a special topic because of reports that these drugs were increasingly available and that the number of users increased. The continuing growth of the club drug problem, particularly ecstasy, has warranted the addition of a club drugs section to the report.

This broad category of drugs includes the following:

• Ecstasy (methylenedioxymethamphetamine, or MDMA), a synthetic, psychoactive substance with stimulant and mild hallucinogenic properties, is the most widely available of club drugs and often used in pill form.
  
  
• Gamma hydroxybutyrate (GHB) is a central nervous system depressant usually sold as an odorless, colorless liquid in water bottles. GHB precursors, gamma butyrolactone (GBL) (a chemical used in many industrial cleaners) and 1,4 butanediol (1,4 BD), convert into GHB in the body and have been sold as nutritional supplements in health food stores and over the Internet, often in powder or capsule form. Because the effects of GHB precursors are similar to those of GHB, many Pulse Check sources do not distinguish between GHB and its precursors.
  
  
• Ketamine is a prescription anesthetic with hallucinogenic and dissociative properties and marketed for human use, but primarily for veterinary use. Ketamine can be used in liquid or powder form.
  
  
• Rohypnol (flunitrazepam) is a benzodiazepine, no longer marketed in the United States but legally prescribed in Mexico and other countries. It has been involved in numerous drug-assisted rapes, but its most common abuse pattern is episodic use by teenagers and young adults as an "alcohol extender" and disinhibitory agent.
  
  
• Nitrous oxide is an inhalant often referred to as laughing gas.
  
  
• Lysergic acid diethylamide (LSD) ("acid") is a hallucinogen, most commonly distributed on blotter paper and taken orally.

The club or rave experience typically involves music, dancing, and socializing and usually lasts through the night. Club drugs are commonly combined with one another and with other illicit drugs or alcohol. As reported in the last Pulse Check, treatment sources had less first-hand knowledge of club drug activity than the law enforcement, epidemiologic, and ethnographic sources, indicating that club drug users have not entered treatment in large numbers. It is important to note that the amount of information received from Pulse Check sources was much greater for ecstasy than for other club drugs.

Although these drugs are categorized as club drugs, the settings and contexts of their use are expanding to include venues other than nightclubs and raves. Moreover, Pulse Check sources continue to suggest that White non-Hispanics are no longer the exclusive sellers and users of the drugs. An increasing number of Pulse Check sources report that ecstasy is being sold with heroin and powder and crack cocaine and that ecstasy users are also using these other illicit drugs. Just as Pulse Check continues to track club drug activity due to concern about increased availability and use, Federal efforts to combat club drugs (ecstasy in particular) include enacting new Federal sentencing guidelines for ecstasy (MDMA) and ecstasy-like substances (including methylenedioxyamphetamine [MDA] and paramethoxyamphetamine PMA]). The new guidelines, effective November 1, 2001, will increase the prison term for the sale of 200 grams of ecstasy (about 800 pills) from 15 months to 5 years, and the penalty for sale of 8,000 pills will also rise from 41 months to 120 months (similar to that of powder cocaine). Pulse Check will continue to track ecstasy and club drug activity and, as new laws are established, will report changes, if any, in the sale and use of club drugs.

ECSTASY AND OTHER CLUB DRUGS: THE PERCEPTION

How do Pulse Check sources perceive the ecstasy problem in their communities? Ecstasy is not considered the most widely abused drug by any law enforcement, epidemiologic, ethnographic, or treatment source, but it is considered the second most widely abused drug by sources in four cities (Billings, Honolulu, Memphis, and Miami), an increase from only one source (the Memphis law enforcement source) during the last reporting period. Additionally, the law enforcement source in Billings is the only source to report it as the drug contributing to the second most serious consequences. No other source reports ecstasy as contributing to the most or second most serious consequences in their communities, and no other club drugs were mentioned as such.

What club drugs are emerging in Pulse Check communities? (Exhibit 1) Although not currently considered the drug contributing to the most serious consequences in any city, ecstasy is reported as an emerging drug of abuse by 25 Pulse Check sources in most cities (15 of 21) across the Nation, with no regional patterns evident. Other club drugs mentioned as emerging include GHB in Denver, Los Angeles, and Honolulu; diverted ketamine in Denver; and Rohypnol (flunitrazepam) and designer amphetamines distributed as samples at raves in Los Angeles. In only six cities (Billings, Birmingham, Chicago, El Paso, New Orleans, and Washington, DC) are club drugs not reported as emerging this reporting period. In four of those cities (Chicago, El Paso, New Orleans, and Washington, DC), club drugs were reported as emerging last reporting period, suggesting that these are now established drugs of abuse in those communities.

Sources: Law enforcement, epidemiologic, ethnographic, and non-methadone treatment respondents; methadone treatment sources did not provide information on club drugs.
*Additional club drugs reported as emerging

ECSTASY AND OTHER CLUB DRUGS: AVAILABILITY, SLANG, AND COMBINATIONS

How available are club drugs in Pulse Check communities? (Exhibit 2) Nearly identical to reports in the last Pulse Check, ecstasy remains the most available of club drugs, with more than 90 percent (38 of 42) of law enforcement, epidemiologic, and ethnographic sources reporting it as widely or somewhat available. Only three sources deem ecstasy as not very available: the epidemiologic sources in Billings and New Orleans and the law enforcement source in El Paso. Availability of club drugs is not based on regional patterns.

As reported in the last Pulse Check, GHB follows ecstasy as the most available club drug, reported as widely or somewhat available by 40 percent (17 of 42) of respondents. GHB is described as not available in only three cities: Denver, El Paso, and Portland (ME). As reported in the last Pulse Check, cities where wide availability is reported are predominantly in the West or South: Billings, Birmingham, Denver, Los Angeles, Miami, New Orleans, and (in the Northeast) New York.

Diverted ketamine is considered somewhat or widely available by 29 percent (12 of 42) of law enforcement, epidemiologic, and ethnographic sources, a lower percentage than that reported in the last Pulse Check. It is not available in three western areas (Billings, Denver, and Honolulu), El Paso, and Sioux Falls. Rohypnol remains the least available of the club drugs, with 19 percent of law enforcement, epidemiologic, and ethnographic sources reporting it as somewhat or widely available. Three (in Los Angeles, New Orleans, and New York) report Rohypnol as widely available, five report it as somewhat available (in Boston, Detroit, El Paso by both sources, and Seattle), and the rest report it as not or not very available. No regional patterns based on ketamine or Rohypnol availability are apparent.

Sources: Law enforcement, epidemiologic, and ethnographic respondents

How has club drug availability changed? (Exhibit 3) According to all law enforcement, epidemiologic, and ethnographic sources who discussed this question (38 of 42), ecstasy availability increased or remained stable between fall 2000 and spring 2001, with 64 percent (27 sources) reporting increases, and 29 percent reporting stable trends. As with availability trends for other club drugs, no regional patterns emerged.

GHB availability continues to show mixed trends, according to 42 law enforcement, epidemiologic, and ethnographic sources: 24 percent report increases (in Birmingham, Billings, Chicago, Denver, Memphis, New Orleans, Portland [ME], Sioux Falls, and Washington, DC, according to both sources), 12 percent report declines (in Columbia [SC], Detroit, Honolulu, Miami, and St. Louis), and most report availability as stable. Ketamine availability increased according to sources in Chicago, Columbia, New Orleans, New York, Portland, and Washington, DC; declined according to sources in Honolulu and Miami; and remained stable according to remaining respondents. Rohypnol availability shows mostly stable trends, with few exceptions: the law enforcement sources in New Orleans and Portland report increases, and declines are reported in Birmingham, El Paso, Honolulu, and Miami.

Back to Exhibits

How are club drugs and their combinations referred to across the country? (Exhibit 4) Slang terms for ecstasy are similar across the Nation. It continues to be generally referred to as "X," although "E" and "roll" are also used. The practice of taking ecstasy is often referred to as "rolling." Ecstasy is often referred to by its design or the shape of the pill: for example, it is called "shamrock" in St. Louis because pills may be clover shaped and "Buddha" in Memphis because pills may be stamped with a Buddha design. Other ecstasy terms vary by locality, and many terms are new this reporting period, suggesting increasing ecstasy availability and use.

GHB continues to be referred to as "G" and ketamine as "K" or "special K." Rohypnol is typically referred to as "roofies" and "rochas" where available. Other terms for these drugs vary by locality, with no particular regional patterns. Use of particular combinations of club drugs varies by city and highlights that multisubstance use or "cafeteria-style use" remains common among club drug users.

Drug or drug combination	Slang term	City
Ecstasy	Tabs	Memphis, New Orleans, and St. Louis
	The bean, beans	Birmingham, Denver, and Miami
	Beads, ills, and illy	Denver
	Candy, shamrock	St. Louis
	Buddha, eenie greenie, Rolanda, and wafers	Memphis
	Dice	Columbia
	Disco biscuits	Birmingham
	Sky	Portland
	Tuna, X-Files	Washington, DC
Two ecstasy pills	Double stacks	Chicago
Thick ecstasy pills	Double stacks	Memphis
The use of more than one ecstasy tablet at a time	Stacking	St. Louis
The use of more than one ecstasy tablet sequentially	Piggybacking	St. Louis
Ecstasy (adulterated with amphetamine)	Speedies	Sioux Falls
Ecstasy (adulterated with mescaline)	Snackies	Sioux Falls
Ecstasy + LSD	Candy flipping	Chicago, Denver, and Philadelphia (new term and practice in this city)
Ecstasy + LSD	Trolling	Miami
Ecstasy +LSD or psilocybin mushrooms	Flipping	Boston
Ecstasy + GHB, keta- mine, or nitrous oxide	E sitting, sitting E	St. Louis
Ecstasy + ketamine	Matrix	Chicago
Ecstasy + PCP (combined in a pill)	Pikachu also the logo on the pill)	Washington, DC
Ecstasy + psilocybin mushrooms	Hippie flipping	Chicago
Ecstasy + Xanax® (alprazolam)	Zanybar	Miami
Ecstasy + Viagra® (sildenafil citrate)	Hammerheading X's and O's	Miami
GHB	Liquid X, liquid E	Boston, Chicago, Denver
	Funk, holy water	Denver
	Gamma	New Orleans
	G juice	St. Louis
	Scoop	Birmingham
	Water	Sioux Falls
Ketamine	Cat	Columbia, Memphis, Washington, DC
	Cat food, kitty, vitamin K	Denver
	In the K-hole (use of ketamine)	Boston
	Thunder	Columbia

Sources: Law enforcement, epidemiologic, ethnographic, and treatment provider respondents Note: A term in bold face indicates that it is reported as new to the respondent's community since the last reporting period.

ECSTASY: THE DRUG

What form does ecstasy come in? (Exhibit 5) According to law enforcement, epidemiologic, and ethnographic sources, the tablet form of ecstasy remains, by far, the most available, followed by powder and liquid forms. Powder ecstasy is widely available according to sources in Boston, Memphis, and Portland (ME); it is somewhat available according to sources in seven other areas (Baltimore, Birmingham, Columbia [SC], Los Angeles, Miami, Philadelphia, and Washington, DC); and it is not or not widely available elsewhere. The epidemiologic source in Sioux Falls regards liquid ecstasy as somewhat available, and the epidemiologic source in El Paso regards it as widely available. All other respondents report liquid ecstasy as not very or not available.

As reported in the last Pulse Check and according to law enforcement, epidemiologic, and ethnographic sources, ecstasy tablets are white or colored, and many are pressed with designs and logos that change periodically. The variety of designs or logos on ecstasy tablets reported has increased dramatically since the last Pulse Check. Designs on ecstasy tablets common across the country include "E," "mitsubishi," "mercedes," "playboy," and cartoon characters. Other designs differ according to city. In Columbia (SC), where a variety of stamped tablets are available, some are home pressed. According to the law enforcement source in Denver, designs on ecstasy seized at raves vary widely, but designs on ecstasy seized in large shipments are the same.

City		Label
	Boston, MA	Mercedes, mitsubishi, and playboy
	Philadelphia, PA	Michelin and mitsubishi
	Portland, ME	E, various numbers
	Columbia, SC	Diamonds, elephants, mickey mouse, and mercedes
	El Paso, TX	E
	Memphis, TN	Arrowheads, cartoon characters, flintstone characters, ladybugs, mercedes, teletubbie characters, and VW beetle
	Miami, FL	Cartoon characters
	New Orleans, LA	Mitsubishi, rolex
	Washington, DC	E, animals, pikachu (contains PCP)
	Chicago, IL	Ferrari
	Detroit, MI	Butterflies, fish, and mitsubishi
	St. Louis, MO	Clovers, mitsubishi, playboy, and statue of liberty
	Sioux Falls, SD	Mitsubishi, nike, suns
	Denver, CO	Cartoon characters, clovers, and stars
	Honolulu, HI	Happy faces, suns, pooh bear, mickey mouse

Sources: Law enforcement, epidemiologic, and ethnographic respondents
Note: A logo in bold face indicates that it is reported as new to the respondent's community since last reporting period.

How is street-level ecstasy packaged? Overwhelmingly, law enforcement, epidemiologic, and ethnographic sources agree that ecstasy tablets are not typically packaged, but sold as loose (or "naked") pills. Additionally, in Denver, El Paso, Miami, and Portland (ME), pills are packaged in plastic bags; in Birmingham and Denver, they are packaged in prescription bottles; in Billings and Honolulu, they are packaged in plastic coin bags; in New Orleans, they are packaged in plastic logoemblazoned coin bags, similar to powder cocaine packaging; in St. Louis, they are packaged in cigarette boxes; in Philadelphia, they are strung on necklaces; and in Seattle, they may be concealed in the ends of glow necklaces.

What are street-level ecstasy prices across the country? (Exhibit 6) The most commonly reported unit of ecstasy sold is one tablet (approximately 100–150 milligrams according to the Miami law enforcement source and 150–250 milligrams according to the Seattle law enforcement source), selling at $12.50–$38 in the Northeast, $20–$30 in the Midwest, $18–$50 in the South, and $20–$45 in the West. Between fall 2000 and spring 2001, according to law enforcement, epidemiologic, and ethnographic sources, prices remained stable, with one exception: according to the law enforcement source in Chicago, prices increased. Other units of ecstasy sold in Pulse Check cities include small tablets (50–150 milligrams) for $10–$20 apiece in Seattle, one jar of 100 pills for $3,000 in Sioux Falls, and wholesale units at $6–$18 in New York and $7–$8 in Miami.

City		Label
	Boston, MA	$20–$35
	New York, NY	$12.50–$38
	Philadelphia, PA	$20–$35
	Portland, ME	$25
	Birmingham, AL	$20–$35
	Columbia, SC	$20–$35
	Memphis, TN	$20–$35
	Miami, FL	$20–$50
	New Orleans, LA	$25–$35
	Washington, DC	$18–$30
	Chicago, IL	$20–$30
	Detroit, MI	$25–$30
	Sioux Falls, SD	$30
	Denver, CO	$20–$25
	Honolulu, HI	$25–$45
	Los Angeles, CA	$20–$30
	Seattle, WA	$20–$30

Sources: Law enforcement, epidemiologic, and ethnographic respondents
*Law enforcement, epidemiologic, and ethnographic respondents in Baltimore, Billings, El Paso, and St. Louis did not provide this information.

What adulterants are added to ecstasy? (Exhibit 7) Similar to the last reporting period, law enforcement, epidemiologic, and ethnographic sources report that ecstasy may be adulterated with other stimulants or may contain no MDMA. Additionally, according to the epidemiologic source in New York, powder cocaine has been sold as powder ecstasy.

City	Adulterant
Boston, MA	Amphetamines, ketamine, LSD, paramethoxyamphetamine (PMA), PCP
Denver, CO	Cocaine, heroin, strychnine
Memphis, TN	Depressants, heroin, methamphetamine
Miami, FL	PMA
Philadelphia, PA	PMA
St. Louis, MO	PCP (sold as ecstasy and referred to as "space")
Sioux Falls, SD	Amphetamine, mescaline
Washington, DC	Methamphetamine, PCP (tablets with pikachu designs)

Sources: Law enforcement, epidemiologic, and ethnographic respondents
Note: An adulterant in bold face indicates that it is reported as new to the respondent’s community since the last reporting period.

Pulse Check sources discuss the wide range of MDMA purity in ecstasy tablets: Boston, MA: According to the law enforcement source, a lot of phony ecstasy is available, and local manufacturers simply use pill molds to make them. The epidemiologic source agrees and states that ecstasy purity fluctuates wildly, though it may be more consistent for buyers who find regular dealers. Los Angeles, CA: Ecstasy pills containing adulterants, referred to as "bunk pills," are common, but the epidemiologic source reports that they are no longer seeing pills containing paramethoxyamphetamine (PMA). St. Louis: According to the epidemiologic source, ecstasy tablet dosage varies greatly due to inconsistent production methods. Washington, DC: It is becoming harder to obtain pure MDMA tablets, according to the epidemiologic source.

Then and Now: How have street-level ecstasy sales changed between fall 2000 and spring 2001?
Ecstasy seller populations are expanding:	Los Angeles, CA: The law enforcement source states that the number of independent ecstasy sellers has increased. Memphis, TN: According to the law enforcement source, ecstasy sellers are expanding to include more high school students. St. Louis, MO: According to the epidemiologic source, more adolescents are becoming involved with ecstasy sales, and now about equal numbers of adolescents and young adults sell the drug.
New seller groups include various ethnicities in the Northeast and Blacks in the South in five Pulse Check cities:	Birmingham, AL Columbia, SC Memphis, TN New York, NY Philadelphia, PA
Ecstasy sales settings have also expanded in cities across the country:	Birmingham, AL: The law enforcement source reports that bars and nightclubs are now catering to underage youth. Bars typically have a "rave night" once a week, where no alcohol is sold, but where customers are selling marijuana and ecstasy. Portland, ME: Law enforcement sources report an increase in the number of local raves. St. Louis, MO: Ecstasy is now more prevalent in high schools and is expanding from raves to schools and from central city areas to suburbs, according to the epidemiologic source. Washington, DC: According to the law enforcement source, ecstasy is increasingly sold on the street.

ECSTASY: SALES

Who sells ecstasy? Young adults are the predominant street-level ecstasy sellers, according to most (20 of 29) law enforcement, epidemiologic, and ethnographic respondents. Five sources (in Birmingham, Denver, New Orleans, St. Louis, and Sioux Falls) report ecstasy sellers as evenly split between young adults and adolescents, and four (in Baltimore, Boston, Memphis, and Seattle) report sellers as primarily adolescents. A summary of ecstasy drug market characteristics appears in exhibit 11 at the end of this section.

Street-level ecstasy sellers tend to be independent, according to most (19 of 30) law enforcement, epidemiologic and ethnographic respondents. Five respondents report ecstasy as organized, and five claim that ecstasy sellers are evenly split between being independent and organized, with organized sellers more involved in raves and nightclub sales than independent sellers. For example, in Denver and Portland (ME), "house dealers" at raves may be in charge of ecstasy sales, with their "runners" distributing drugs to individual buyers; in Miami, organized sellers in clubs tend to be connected with drug trafficking; and in Los Angeles, sellers tend to be affiliated with organized crime. In Columbia (SC) and Denver, independent sellers are college students or those who have access to the college scene.

Are ecstasy sellers involved in other crimes? Most law enforcement respondents (13 of 19) report that street-level ecstasy sellers are not typically involved in other crimes. Reports of "somewhat" or "very likely" involved in other crimes are given by six respondents (in Baltimore, Detroit, Portland (ME), Memphis, Miami, and New Orleans). Furthermore, ecstasy dealers are not typically involved in violence, according to 16 of 17 respondents. Only the Baltimore source associates violent crimes with ecstasy sellers. Other crimes associated with ecstasy sellers include drug-assisted rape in Baltimore, Denver, Los Angeles, and Memphis; domestic violence in Baltimore, gang-related activity in Honolulu; and prostitution (users prostituting for the drug) in Birmingham.

Epidemiologic and ethnographic respondents report that ecstasy dealers are less involved in other crimes than do the law enforcement sources. Most (seven of eight) epidemiologic/ ethnographic respondents report those selling ecstasy are "not at all" or "not very likely" to be involved in other crimes. Similar to the Baltimore law enforcement response, according to the epidemiologic source, ecstasy sellers are somewhat likely to be involved in other crimes in that city. Other crimes reported by epidemiologic and ethnographic sources are typically nonviolent crimes, although ecstasy sellers are reported to be involved in prostitution and violent crimes in Baltimore and gang-related crimes in Memphis.

Do ecstasy sellers use their own drug? Similar to information in the last Pulse Check, nearly all (25 of 27) law enforcement, epidemiologic, and ethnographic respondents believe that ecstasy sellers are somewhat or very likely to use the drug. Only in Baltimore (by the epidemiologic source) and Miami (by the law enforcement source) are ecstasy sellers reported as not very likely to use the drug.

Where is street-level ecstasy sold? (Exhibit 8) According to 20 law enforcement respondents, ecstasy sales take place in a wide variety of areas, mostly central cities and suburbs. Law enforcement sources in six cities (Columbia [SC], Denver, New York, Philadelphia, Portland [ME], and Washington, DC) report ecstasy sales in all areas of the cities. Similarly, according to epidemiologic and ethnographic respondents, the locations of ecstasy sales vary widely, occurring mostly in central city and suburban areas.

Sources: Law enforcement, epidemiologic, and ethnographic respondents
*For sales settings law enforcement, epidemiologic, and ethnographic sources responded, except for the following: the law enforcement source in El Paso and Seattle and the epidemiologic source in Billings, Columbia (SC), El Paso, Los Angeles, Honolulu, New Orleans, Philadelphia, Portland (ME), Sioux Falls, and Seattle. For users settings, epidemiologic and ethnographic sources responded, except for the sources in Billings, Boston, and St. Louis.

Raves and concerts, nightclubs and bars, college campuses, private residences, private parties, and inside cars remain the primary settings for ecstasy sales as reported by law enforcement, epidemiologic, and ethnographic sources. Reinforcing the widespread availability of ecstasy, common sales settings also include schools, streets, shopping malls, and the Internet. Less common settings include public housing developments in Miami, New Orleans, and Sioux Falls; playgrounds or parks in New Orleans and Honolulu; hotels and motels in Columbia (SC); and many types of social gatherings, regardless of setting, in Baltimore.

Ecstasy sales and user settings: A closer look The numbers of different ecstasy sales settings and user settings mentioned tend to be larger in the southern and western cities, possibly indicating wider availability and use in those regions. Ecstasy sales settings tend to overlap with user settings in most cities, but typically more settings are mentioned for sales than for use.

How is street-level ecstasy sold? Ecstasy sales typically involve handto-hand sales through acquaintance networks, according to most (24 of 29) law enforcement, epidemiologic, and ethnographic respondents. Additionally, beepers or cell phones are used in 10 cities (Baltimore, Billings, Chicago, Detroit, Honolulu, Memphis, Miami, New Orleans, St. Louis, and Washington, DC). According to law enforcement respondents, the drug is distributed by delivery-type services in five cities (Baltimore, Birmingham, Memphis, New Orleans, and St. Louis), and it is sold via the Internet in four cities (Detroit, Honolulu, Memphis, and New Orleans). Conversely, epidemiologic and ethnographic respondents do not report the use of delivery-type services or the Internet for ecstasy sales. According to the Memphis law enforcement source, ecstasy transactions are conducted via introductions; that is, sellers are introduced to potential buyers by a liaison or mutual acquaintance who can vouch for the seller.

What other drugs do ecstasy dealers sell? According to most (12 of 18) law enforcement respondents, ecstasy sellers also tend to sell other drugs. By contrast, according to most (6 of 8) epidemiologic and ethnographic respondents, ecstasy sellers do not typically sell other drugs. Other drugs sold by ecstasy dealers, according to law enforcement, epidemiologic, and ethnographic sources, include other club drugs (especially GHB, ketamine, and LSD), heroin, powder and crack cocaine, marijuana, methamphetamine (where it is available), and other diverted prescription drugs. The Philadelphia law enforcement sources states that LSD is often sold as an ecstasy substitute.

ECSTASY: THE USERS

How has the number of novice ecstasy users in treatment changed? (Exhibit 9) According to most (9 of 15) non-methadone treatment respondents, the number of novice ecstasy users in treatment (defined as any drug treatment client who has recently begun using ecstasy) has increased since the last reporting period, with the remaining respondents reporting stable trends. Only one methadone treatment source (in Boston) responded to the question, reporting an increasing number of novice ecstasy users in treatment.

Who uses ecstasy? Similar to information in the last Pulse Check, ecstasy users tend to be young (13–30 years), evenly split between genders, White, and of middle to high SES, according to epidemiologic, ethnographic, and non-methadone treatment sources. In general, methadone treatment sources did not provide information about club drug users.

Of 17 epidemiologic and ethnographic respondents, most (15) report that ecstasy users are predominantly White, and of these, most (13) report that Whites are overrepresented compared with the general population in their cities. Only in Baltimore are Blacks the predominant ecstasy users, but they are underrepresented compared with the general population in that city. In El Paso, Hispanics are the predominant ecstasy users, at proportions about equal to that of the general population. Most ecstasy users range from middle to high SES, according to 18 epidemiologic and ethnographic sources, with 2 exceptions: in Baltimore, predominant users are of low SES, and in Portland (ME), ecstasy users are distributed somewhat evenly among all SES categories. A summary of ecstasy users and use characteristics appears in Exhibit 12 at the end of this section.

Non-methadone treatment provider respondents (12) agree with epidemiologic and ethnographic sources and report that ecstasy users in treatment tend to be adolescents and young adults, with the Honolulu source reporting the emerging group of ecstasy users in treatment as mostly preadolescents. Also similar to reports by epidemiologic sources, most (8 of 13) treatment respondents state that ecstasy users in treatment are split evenly between genders, and most (8 of 13) report ecstasy users in treatment as predominantly Whites and overrepresented or about proportionate to the general population. Although most treatment respondents (9 of 12) state that ecstasy users in treatment are predominantly of middle SES, two (in Memphis and Billings) report them as predominantly of low SES, and the Los Angeles source reports them as of both low and middle SES. Additionally, in three cities (Boston, New Orleans, and Seattle), emerging ecstasy users in treatment are predominantly of low SES.

Then and Now: How has ecstasy use changed (fall 2000 vs spring 2001)? Parallel to the expansion of ecstasy sales and seller populations, ecstasy use is expanding to new users groups and new settings in some Pulse Check areas:
Adolescent ecstasy users are increasing in number, according to epidemiologic and ethnographic sources in seven sites across the country:	Columbia, SC Los Angeles, CA Memphis, TN Miami, FL St. Louis, MO Sioux Falls, SD Washington, DC
Ecstasy use is expanding to non-White and Hispanic populations:	Los Angeles, CA Honolulu, HI Memphis, TN Miami, FL
Ecstasy use is expanding to new settings and contexts in several sites:	Boston, MA: Settings for new ecstasy users include streets, public housing developments, and cars, according to the methadone treatment source. Denver, CO: According to the non-methadone treatment source, new ecstasy user settings include supermarkets and nightclubs. Miami, FL: Ecstasy use is moving from a specific event or place to more common daily use, and some users are beginning to use the drug alone and in private, according to the epidemiologic source. Additionally, private residences, around schools, and private parties were added to the list of user settings. Furthermore, according to the law enforcement source, as ecstasy activity has skyrocketed, the popularity of ecstasy use at raves has shifted to private parties. St. Louis, MO: The epidemiologic source states that, in the past, ecstasy use was confined to raves and dance clubs in the central city, but use has moved into the suburbs and into new settings, paralleling increases in adolescent use. Sioux Falls, SD: According to the epidemiologic source, more indoor raves are taking place in the area, with increasing advertising and promoting.

Sources: Non-methadone treatment respondents
*Sources in Baltimore, Birmingham, Chicago, Detroit, Los Angeles, New Orleans, and Washington, DC, did not provide this information; Billings has two non-methadone treatment respondents.

Where do ecstasy users tend to reside? According to 18 epidemiologic and ethnographic respondents, locations of ecstasy users' residences differ by region. For example, in the Northeast, ecstasy users reside predominantly in central cities (except in Philadelphia, where they reside in both the central city and suburbs); in the West, they reside predominantly in central cities and suburbs; in the South, they reside in central cities, rural areas, and suburbs; and in the Midwest, they reside predominantly in suburbs (except in Chicago, where they reside in both the central city and suburbs).

Where and in what contexts do ecstasy users tend to use the drug? (Exhibit 8) Similar to settings for ecstasy sales, settings for ecstasy use, in descending order of the most frequently mentioned by law enforcement, epidemiologic, and ethnographic respondents, include raves, nightclubs, private parties, private residences, and college campuses. Since the last reporting period, several new user settings have been added to the list, including playgrounds and parks, public housing developments, shopping malls, streets, inside cars, and around schools. Ecstasy use occurs predominantly indoors, according to epidemiologic and ethnographic sources. All 18 respondents report that ecstasy is predominantly used in groups or among friends, but in Miami, ecstasy users are beginning to use the drug alone and in private.

How is ecstasy used and what other drugs do ecstasy users take? Predominant route of administration among ecstasy users remains oral, according to epidemiologic, ethnographic, and non-methadone treatment respondents. Additionally, in Miami and St. Louis, some users are beginning to snort or inject the drug; in New Orleans, it is mixed in beverages; and in Birming-ham and Washington, DC, it is dissolved in hot beverages.

Ecstasy continues to be used in combination with other drugs, including other club drugs (such as LSD, psilocybin mushrooms, GHB, ketamine, and nitrous oxide) across the country; marijuana in the South, West, and Philadelphia; methamphetamine in the West, Memphis, Washington, DC, and Chicago (where the practice is rare); heroin in Memphis, Miami, and St. Louis; powder cocaine in Memphis and Seattle; and diverted prescription depressants in Miami. "Candy flipping," the use of ecstasy and LSD, was mentioned in several areas: Chicago, Denver, Hono-lulu, Memphis, Miami, Philadelphia, and Washington, DC. In Los Angeles and Miami, Viagra® (sildenafil citrate) is used with ecstasy. Exhibit 4 lists slang terms for club drug combinations.

According to non-methadone treatment respondents, the most common club drug combination is ecstasy and marijuana. Emerging combinations include ecstasy and diverted OxyContin® (a time-release, high-dosage formulation of oxycodone) in Boston; ecstasy and LSD in Columbia (SC); and ecstasy and high-purity methamphetamine ("ice") or cocaine in Honolulu.

In several Pulse Check cities Viagra® has recently been reported as sold or used with ecstasy. Honolulu: Viagra® (sildenafil citrate) is sold with ecstasy or GHB at raves. Miami: Viagra® used in combination with ecstasy is referred to as "X's and O's" or "hammerheading." Los Angeles: Viagra® is often used with ecstasy.

OTHER CLUB DRUGS: THE DRUGS

What are the common forms of GHB, ketamine, and Rohypnol, and how are they packaged? The most common form of GHB available is liquid, typically clear, as reported by law enforcement, epidemiologic, and ethnographic respondents. Additionally, a powder form of the drug is somewhat available in New Orleans and Los Angeles. GHB as a liquid is packaged in a variety of ways depending upon locality. Common packaging includes plastic bottles (typically water, sports drink, or soda bottles) in Birmingham, Chicago, Columbia (SC), Detroit, Los Angeles, Memphis, Miami, New Orleans, and St. Louis; eyedropper bottles in Chicago, Los Angeles, and Miami; and vials (glass or plastic) in Billings, Boston, Miami, Philadelphia, St. Louis, and Washington, DC. GBL and 1,4 BD (GHB precursors) are available in some areas, including Boston, Los Angeles, Miami, New Orleans, and Sioux Falls. Many respondents do not distinguish between GHB and its precursors.

Ecstasy users in treatment: A closer look The most common treatment referral sources for ecstasy users in treatment, according to 13 non-methadone treatment respondents, are health care providers (in Billings, Columbia [SC], Denver, and Miami), court or criminal justice referrals (in Denver, Miami, St. Louis, and Sioux Falls), and secondary school referrals (in Denver, Los Angeles, and St. Louis). The non-methadone treatment source in St. Louis comments that most ecstasy users in treatment who were referred by schools were sent to treatment because they were caught with marijuana on school property. Similarly, according to the Boston methadone treatment source, another drug besides ecstasy, typically abuse of diverted OxyContin®, tends to be the primary reason an ecstasy user is in treatment. According to the non-methadone source in Columbia, ecstasy users in treatment initially claim to be addicted to drugs other than ecstasy, but clients often later reveal that ecstasy tends to be their primary drug of use. Six of 10 non-methadone treatment respondents (in Denver, Honolulu, Memphis, Portland [ME], St. Louis, and Sioux Falls) report that ecstasy clients typically use the drug one to two times per week, three respondents (in Los Angeles, Miami, and Sioux Falls) report that ecstasy clients use one to two times per month, and the source in Columbia (SC) reports that they use three to four times per week. In Honolulu, the frequency of ecstasy use among adolescent clients has increased since the last reporting period.

Diverted ketamine is available predominantly in liquid and powder forms, according to responding law enforcement, epidemiologic, and ethnographic sources. It is typically bought and sold as a liquid and taken orally or converted into powder for snorting. Additionally, the liquid form is injected in Boston, Detroit, and Washington, DC; the drug is available in pill form in Los Angeles and New York; and the liquid form is poured in drinks in Boston. Ketamine is illegally sold primarily by the plastic bag as a powder or by the vial as a liquid. Furthermore, according to the Columbia (SC) law enforcement source, sellers transfer ketamine from prescription vials into plain vials to avoid connection with the pharmacy or veterinary office from which it was stolen. The Memphis law enforcement source states that ketamine powder is sold in foil or in folded paper, and the New Orleans law enforcement source reports that liquid ketamine is sold in plastic soda or sports drink bottles. Ketamine is sold in powder form if it is used in clubs and raves in Washington, DC, and in liquid form if it is to be delivered outside of the District, according to the law enforcement source.

Rohypnol is available in pill form, according to respondents in all areas where it is available, and is sold as loose pills, except in New Orleans (according to the law enforcement source), where it is packaged in plastic bowls or small plastic bags.

How much are GHB, ketamine, and Rohypnol across the country? (Exhibit 10) Where available, GHB sells primarily as a liquid by the dose, with a dose usually comprising bottle capfuls or drops. One dose (a "shot" or "swig") costs $5–$20 in Pulse Check cities. Additionally, in Birmingham, dealers are putting GHB in water guns, and users are paying for it by the squirt. In Miami, candy, typically lollipops, is dipped in GHB and sold. In Columbia (SC), a product containing GHB (liquid Verve®) was given away as a promotional item in a nutritional supplement store. In Miami, a 32 ounce bottle of GBL or 1,4 BD sells for $40–$70. Reported prices for GHB have remained stable since the last reporting period, except in Los Angeles, where they have dropped due to increased availability.

The prices for diverted ketamine vary based on the form of the drug and unit available. Prices have remained stable since the last reporting period, with two exceptions: increases due to decreasing availability are reported in Los Angeles and Portland (ME). Rohypnol prices are reported in only five cities (Chicago, El Paso, Los Angeles, Memphis, and New Orleans) and range widely (from $1 to $25), but have not changed since the last reporting period.

City	Most Common Unit Sold	Price
GHB
Birmingham, AL	1 ounce	$60
Boston, MA	Capful	$5
Chicago, IL	Capful	$15–$20
Denver, CO	Capful	$5–$10
New York, NY	1 gram	$30
Los Angeles, CA	Capful (one shot)	$5–$20
Memphis, TN	Capful	$20
Miami, FL	One swig or hit	$5–$10
New Orleans, LA	Capful	$15–$20
Philadelphia, PA	One vial (one dose)	$10–$20
Washington, DC	Thimbleful	$10
Ketamine
Boston, MA	1-ounce bottle of liquid	$50
Chicago, IL	One bag of powder	$10–$20
Columbia, SC	˝-ounce liquid vial	$125
Denver, CO	One dose	$25
Detroit, MI	100 milligrams of liquid	NR
Los Angeles, CA	One pill 0.2 grams of powder	NR $20
Memphis, TN	0.1 gram of powder	$10
Miami, FL	One vial	$40
New Orleans, LA	0.35-gram bag of powder	$15–$20
New York, NY	One pill	$40–$50
Philadelphia, PA	One liquid vial	$10–$20
Portland, ME	0.3-gram bag	$40
Washington, DC	1/8 gram of powder 150-milligram bag	$20 $25
Rohypnol
Chicago, IL	One pill	$5
El Paso, TX	One pill	$1–$5
Los Angeles, CA	One pill	$6–$10
Memphis, TN	One pill	$5–$10
New Orleans, LA	One pill	$15–$25

Sources: Law enforcement, epidemiologic, and ethnographic sources

OTHER CLUB DRUGS: THE SALES

Who sells other club drugs, and how and where are they sold? (Exhibit 11) According to most law enforcement, epidemiologic, and ethnographic respondents, GHB, ketamine, and Rohypnol sellers and sales characteristics are similar to those of ecstasy, with a few differences, as shown in Exhibit 11.

Variable	Ecstasy	GHB	Ketamine	Rohypnol
Age	18–30 years	13–30 years	13–30 years	13–30 years
Organization	Independent	Independent	NR	NR
Sales method	Hand-to-hand through acquaintance networks		NR	NR
Likeliness to be involved with other crimes or violence	Not likely	Not likely, with the exception of drug- assisted rape	Not likely, with the exception of vet- erinary clinic thefts to obtain the drug	Somewhat likely especially especially drug-assisted rape and nonviolent crimes
Likeliness to use the drug	Somewhat or very likely	Somewhat likely	Somewhat or very likely	Not very likely
Indoors or outdoors	Indoors and outdoors	Indoors	Indoors	Indoors
Most common settings	Raves/concerts, nightclubs, college campuses, and private residences and parties, but vary widely		Private parties and nightclubs	Raves
Likeliness to be sold with other drugs	Somewhat likely, especially with other club drugs and some major drugs	Somewhat likely, espe- cially with other club drugs and marijuana	NR	NR
Other	NR	Precursors sold at health food and vitamin stores or gyms	NR	NR

Sources: Law enforcement, epidemiologic, and ethnographic respondents

OTHER CLUB DRUGS: THE USERS

Who uses GHB, ketamine, and Rohypnol and where are the drugs used? (Exhibit 12) Regardless of the specific drug and similar to seller characteristics, club drug user characteristics are similar, with a few key differences noted in Exhibit 12.

Variable	Ecstasy	GHB	Ketamine	Rohypnol
Age	13–30 years	13–30 years	13–30 years	13–30 years
Gender	Evenly split	Male	Male	Male
Race/ethnicity	Whites and over-represented	Whites and over-represented	Whites and over-represented	Whites and over-represented
SES	Middle to high	Middle	Middle	Middle
Indoors or outdoors	Indoors	Indoors	Indoors	Indoors
Context	In groups/among friends	In groups/among friends	In groups/among friends
Most common settings	Raves/concerts, nightclubs, and private residences and parties, but vary widely
Likeliness to be combined with other dugs	Very likely, especially with other club drugs, heroin, powder and crack cocaine, and marijuana	Likely, especially with ecstasy		Likely, especially with marijuana
Other characteristic	Students	NR	NR	Around the Mexican border, users tend to be Hispanic and overrepresented

Sources: Law enforcement, epidemiologic, and ethnographic respondents

With what other drugs are GHB, ketamine, and Rohypnol used? Club drug combinations include GHB with alcohol across the country; with ecstasy in Chicago, Los Angeles, Miami, and Seattle; with marijuana in Birmingham and Miami; and with ketamine in Denver. Ketamine is combined with ecstasy in Chicago, Miami, and Washington, DC; with marijuana in Detroit and Miami; with LSD in Chicago; and with methamphetamine in Birmingham. Rohypnol is combined with marijuana in Birmingham and Miami, LSD and ecstasy in Miami, heroin and powder cocaine in El Paso, where the speedball effect (in this case, Rohypnol, a depressant, and cocaine, a stimulant) is reported to "soften the fall when users are coming down from the high."

Then and now: How have GHB, ketamine, and Rohypnol sales and users changed (fall 2000 vs spring 2001)?
Changes among GHB and Rohypnol sellers are reported by law enforcement sources in a few Pulse Check cities:	Birmingham, AL, and New Orleans, LA: More races and ethnicities are involved in selling GHB. Los Angeles, CA: The number of independent GHB and Rohypnol sellers increased. Washington, DC: GHB has recently been seized with methamphetamine, suggesting that they may be produced at the same clandestine labs. Los Angeles, CA, and Memphis, TN: Adolescent users increased. Sioux Falls, SD: A group of high school boys has emerged as users.
GHB use has expanded to new user groups in several Pulse Check sites, according to epidemiologic and ethnographic sources:	Los Angeles, CA: An emerging group of high SES users is reported. Miami, FL: Emerging groups include Blacks and central city dwellers. Emerging groups tend to be evenly split between the genders. New Orleans, LA: Homosexual males are now the primary GHB users.
Ketamine and Rohypnol use and user characteristics have changed in several Pulse Check cities, according to epidemiologic and ethnographic sources:	Boston, MA: Although ketamine is used predominantly at private residences, the emerging group of users tends to use the drug in nightclubs and bars. Miami, FL: Adolescents are an emerging ketamine user group. Washington, DC: Young adults are the most likely age group to use ketamine, but adolescents are a growing user population. The drug is usually snorted, but injecting has increased. Birmingham, AL, and Memphis, TN: Rohypnol use declined. Los Angeles: Rohypnol use increased. Sioux Falls, SD: Adolescents are an emerging Rohypnol user group.