Major Meta-Study on the Health Effects of Cannabis

Summary of findings, with a lot of the references and numbers removed:

Results: 101 meta-analyses were included. From RCTs supported by high to moderate certainty, cannabis based medicines increased adverse events related to the central nervous system, psychological effects, and vision in people with mixed conditions (GRADE=high), improved nausea/vomit, pain, spasticity, but increased psychiatric, gastrointestinal adverse events, and somnolence among others. (GRADE=moderate).

Cannabidiol improved 50% reduction of seizures and seizure events (GRADE=high), but increased pneumonia, gastrointestinal adverse events, and somnolence (GRADE=moderate).

For chronic pain, cannabis based medicines or cannabinoids reduced pain by 30% (0.59 (0.37 to 0.93), GRADE=high), across different conditions (n=7), but increased psychological distress.

For epilepsy, cannabidiol increased risk of diarrhoea (2.25 (1.33 to 3.81)), had no effect on sleep disruption (GRADE=high), reduced seizures across different populations and measures (n=7), improved global impression (n=2), quality of life, and increased risk of somnolence (GRADE=moderate).

In the general population, cannabis worsened positive psychotic symptoms and total psychiatric symptoms (GRADE=high), negative psychotic symptoms, and cognition (GRADE=moderate).

In healthy people, cannabinoids improved pain threshold, unpleasantness (GRADE=high). For inflammatory bowel disease, cannabinoids improved quality of life (GRADE=high).

For multiple sclerosis, cannabinoids improved spasticity, pain, but increased risk of dizziness, dry mouth, nausea, somnolence (GRADE=moderate).

For cancer, cannabinoids improved sleep disruption, but had gastrointestinal adverse events (GRADE=moderate).

Cannabis based medicines, cannabis, and cannabinoids resulted in poor tolerability across various conditions (GRADE=moderate).

Evidence was convincing from observational studies (main and sensitivity analyses) in pregnant women, small for gestational age, low birth weight; in drivers, car crash; and in the general population, psychosis. 

Harmful effects were noted for additional neonatal outcomes, outcomes related to car crash, outcomes in the general population including psychotic symptoms, suicide attempt, depression, and mania, and impaired cognition in healthy cannabis users (all suggestive to highly suggestive).

Conclusions Convincing or converging evidence supports avoidance of cannabis during adolescence and early adulthood, in people prone to or with mental health disorders, in pregnancy and before and while driving. Cannabidiol is effective in people with epilepsy. Cannabis based medicines are effective in people with multiple sclerosis, chronic pain, inflammatory bowel disease, and in palliative medicine but not without adverse events.

Other than the rather remarkable effect on seizures and a modest effect on nausea (n.b., we have much better anti-nausea drugs), I think pretty much all the positive findings here can be explained by the simple fact that people like being high. This study also adds to the data showing that long-term cannabis use is dangerous for your mental health, although possibly not any more dangerous than whiskey.

In Mexico, the Godfather was the Defense Minister

I don't know what to say about the news that the Mexico's former Defense Minister has been arrested as a drug kingpin, joining the former head of their equivalent to the FBI. In fact the government turned to the military to fight the drug cartels because they worried that all of their police had been compromised. And now that we think the military leadership has also been compromised, who can the people call on for help?

The vast sums of money in illegal drugs are too powerful, it seems, for governments to resist. 

Where does that leave us? Legalization, I suppose, but making addictive drugs widely available is a disaster of its own, and we have shown in the US with a large-scale experiment on opioids.

I used to have strong opinions about this but now I doubt everything.

Opioids and the Other Excess Deaths

I have seen modeling that says we are undercounting Covid-19 deaths because deaths in toto have gone up much more than the confirmed coronavirus deaths, which is probably true, but they then argue or assume that we should attribute all of the excess deaths to the coronavirus. But maybe not:

Amid social distancing, authorities nationwide are reporting a surge in fatal opioid overdoses. Addiction and recovery advocates say the U.S. is now battling two epidemics at once. . . .

In Franklin County, Ohio, where Lynn lives, the coroner is warning residents of a continued spike in drug deaths, including six on April 24. One week before, the coroner announced that five people died in a span of 12 hours. In February, overdoses were so prevalent the coroner said she might need a temporary morgue to handle the deluge.

“Folks for the fourth Friday in a row we have had a surge of overdose deaths: 6 yesterday,” Dr. Anahi Ortiz posted on Facebook on April 25. . . . Montgomery County, Ohio—which is home to Dayton and was considered the country’s overdose capital in 2017—is reporting a 50 percent jump in overdoses over last year. Coroner Kent Harshbarger suggested to one local news outlet this increase could be closer to 100 percent: “March had around 42 which, our normal baseline is somewhere in the 20s usually. So 42 is a significant increase.”

Indeed, authorities in counties across Florida, Texas, Pennsylvania and New York are also reporting rises in overdoses during the COVID-19 crisis.

I imagine that if you are an addict struggling to keep your habit under control, boredom and stress can't help.

Ancient Stoners

In 2013 Chinese archaeologists excavated a cemetery on the Pamir Plateau of western China that dates to around 500 BC. This is a dry, desert area and much wood was preserved.

Ten of the skeletons were buried with incense burners on a common pattern. These were wooden blocks, with a hollow dug into them that had been filled with rocks.

The braziers contained a burned residue that intrigued the archaeologists, so they submitted samples for analysis by gas chromatography to figure out what it was. The results came back with a high level of cannabinol (CBN), cannabidiol (CBD) and cannabicyclol (CBL), all of which come from cannabis.

THC, the active ingredient, does not survive for any length of time, but in modern plants the level of THC is closely correlated with the level of CBN. The level of CBN in these samples was highly elevated compared to what you would find in ordinary hemp being grown for fiber. So it looks like these folks had specially bred their plants to increase the THC yield. So they could get high more easily.

Based on what we know from Scythians at the western end of the Eurasian plain, at about the same time, cannabis was used ritually, both for funeral rites and to help induce shamanistic trance. But the line between ritual and fun has always been a blurry one.

In New Jersey, Legalizing Pot and Expunging Past Convictions

New Jersey's new governor made marijuana legalization a key plank in his election platform, and the legislature has been working on a bill ever since. It has been tied up by details of taxation and the like, and by a push by black legislators to tie legalization to a bill expunging past convictions for drug possession:

Supporters of the proposal in New Jersey to expunge criminal records say strict drug laws in the state have long unfairly targeted minorities: A black New Jersey resident is three times more likely to be arrested on marijuana-related offenses than a white resident, a recent study found.

As Trenton begins to debate a marijuana bill approved on Monday by a joint legislative committee, creating an efficient process for tossing out past convictions has become central to gaining support from lawmakers who represent predominantly African-American communities. . . .

The bill that would make recreational marijuana legal also would pave the way for those with past convictions for small amounts of marijuana to have their records wiped clean. But some lawmakers want to go much further.

Mr. Holley and Senator Sandra B. Cunningham, a Democrat from Jersey City, are backing a plan aimed at clearing more serious drug convictions, including low-level sales of drugs other than marijuana, such as cocaine and heroin. Their proposal would also erase some other nonviolent convictions.

Holley and Cunningham imagine a process whereby people who have been out of trouble for a decade can get old drug-related convictions erased from their record, but they would have to apply and be approved.

Erasing past convictions for something now legal seems reasonable to me, but I am cautious about broader expungement. Studies have shown that if employers can't get data on past legal trouble they become more racist, because they assume that black people are more likely to be criminals and people without records have no way to prove it.

More broadly this gets at the fundamental question of justice: can people reform? It seems to me that many sorts of convictions ought to be ignored after people have been clean for ten years, but a big faction in our country thinks that people who have done bad things can never be trusted.

Is the Opioid Epidemic Finally Cresting?

After a decade of going up by leaps and bounds, the death rate in the US from opioids seems to have stabilized and may even have declined slightly this year. This is preliminary data and we won't have the real results for months, but it is certainly encouraging. The Times sent a reporter to Dayton, Ohio, where opioid deaths are down 50% from last year, to investigate what might behind it. For one thing, the hardest-hit states have gotten serious about treatment:

Mayor Nan Whaley thinks nothing has had as big an impact on overdose deaths as Gov. John Kasich’s decision to expand Medicaid in 2015, a move that gave nearly 700,000 low-income adults access to free addiction and mental health treatment.

In Dayton, that’s drawn more than a dozen new treatment providers in the last year alone, including residential programs and outpatient clinics that dispense methadone, buprenorphine and naltrexone, the three medications approved by the F.D.A. to treat opioid addiction.

“It’s the basis — the basis — for everything we’ve built regarding treatment,” Ms. Whaley said in an interview at City Hall. “If you’re a state that does not have Medicaid expansion, you can’t build a system for addressing this disease.”

Naloxone and the knowledge of how to administer it have also been widely pushed, which has saved quite a few lives, and the dangerous drug Carfentanil has largely disappeared from the city, probably because it was so dangerous that even dealers and addicts are now shunning it. Pressure on doctors to write fewer opioid prescriptions may also be a factor.

Good economic times may also be helping; the epidemic took off as a side-effect of hopeless unemployment in the wake of the financial crisis, and that has changed in many places.

The opioid boom may also have been a sort of fad that took off as fads often do, an "everybody's doing it so maybe I'll give it a try" sort of thing, and maybe the number of deaths and the amount of depressing news coverage have dampened the allure.

Not that America's drug problems are anything close to ending. In places where heroin use is down, meth use is up, a real devil's bargain, and even if opioid abuse goes back down to the level of ten years ago that would still be a terrible waste of life. The sad fact is that living just hurts for millions of people, and what to do about that I have no idea.

Drug Crisis?

Data to think about:

Alcohol is responsible for over one in 20 of all deaths worldwide, according to the most recent edition of a World Health Organization (WHO) report that comes out every four years. . . .

According to the WHO data, approximately 7.2 percent of premature deaths worldwide are linked to alcohol, and as well as 5.3 of all deaths in general.

"Are linked to" might be doing a lot of work here, but it is good to remember that alcohol is by far the most deadly drug.

Drug Overdose Deaths Still Rising

Preliminary data for 2017, from the CDC, shows about 72,000 deaths from drug overdoses nationwide, up more than 6 percent from the year before. As you can see from the graph above, synthetic opioids (mainly Fentanyl) are the main culprit. What struck me about this graph was the big rise in deaths from cocaine and methamphetamine ("psychostimulants"). I thought that was old news, but according to this graph more than 20,000 Americans died from those drugs last year.

We have so many ways to poison ourselves.

Suicide and Addiction in a Pretty Nice Place

Depressing story by Juliet Macur in the Times about Madison, Indiana, an ordinary town with a suicide rate 3.2 times the national average:

The unemployment rate here in Jefferson County is around 4 percent, just about the same as it is nationwide, and among those employed residents, about a quarter work in manufacturing. The county is mostly rural, and overwhelmingly white. In Madison, which is marked by three riverfront smokestacks that can be seen for miles, the median household income in 2016 was about $51,500, and two of every 10 children under 18 lived in poverty.

The tourists who travel here see Madison’s antique shops and frequent its art, music, food and boat-racing festivals. But beneath all that are the crises that threaten to drag this town under: suicide, depression, child neglect, abuse and addiction to drugs. 

I see this as the question of our age: why so much hopelessness among young people, even in towns with jobs? Why such a pervasive sense that things are out of whack, that the world is in decline? Why are we so fearful? Why is crazed alarmism such an effective political strategy?

I go back and forth in my own mind, from "things aren't really any worse than they have always been" to "something vital is missing from our society."

Is it too much news, all of it focusing on the bad? Is it an evolutionary misalignment between the hungry village life we evolved for and the mass society and material abundance we have ended up in?

Macur's story focuses on a high school football coach who lost his own brother and is now determined to help kids stay alive. It's easy to be cynical, but if high school sports rivalries won't give small town folks the excitement and sense of community they need, what will?

I don't have any answers, other than a sense that our public culture of outrage, blame, anger, partisan hate, and general woefulness is making things worse.

Legal Pot Sellers Hate the Black Market

LA Times:

Six weeks after the state began licensing marijuana farming and sales, officials have received a flood of complaints about illegal pot operations and demands for a start to tough enforcement.

Many of the 304 complaints received in recent weeks are from newly licensed businesses that say they are being harmed financially by the continuing illegal market. . . .

"We really need enforcement in California given that the local licensees are really having to fight against the black market," Stephanie Hopper, a representative of the firm Canndescent, which grows and sells marijuana in California, told the panel.

So much for saving a lot of money in policing.

How Much of the Opioid Epidemic is Caused by Economic Hard Times?

Not very much, according to these academics:

The United States is in the midst of a fatal drug epidemic. This study uses data from the Multiple Cause of Death Files to examine the extent to which increases in county-level drug mortality rates from 1999-2015 are due to “deaths of despair”, measured here by deterioration in medium-run economic conditions, or if they instead are more likely to reflect changes in the “drug environment” in ways that present differential risks to population subgroups. A primary finding is that counties experiencing relative economic decline did experience higher growth in drug mortality than those with more robust growth, but the relationship is weak and mostly explained by confounding factors. In the preferred estimates, changes in economic conditions account for less than one-tenth of the rise in drug and opioid-involved mortality rates.

What they find instead is that the biggest factor influencing drug use in any community is the availability and cost of drugs.

This is just one study, but I would not be surprised if it is right. But not because I think the epidemic has nothing to do with “despair.” As we know, in our wealthy world economic troubles manifest largely in psychological terms, that is, a rise in the unemployment rate from 5% to 9% can make a lot more than 4% of the people miserable. So a whole community's sense that times are bad and the future is bleak might not show up very clearly in the raw economic numbers.

Take the paradigmatic case of the coal country in southern West Virginia and eastern Kentucky. These are poor areas, but they have always been poor. It's just that the industries they did have -- coal mining, manufacturing -- are rapidly declining. This makes their “medium-run economic conditions” only a little worse than they were, but it has a huge impact on the overall mood of those places. They are depressed and distressed, even if their median income is much higher than what we would consider a boom town in Nigeria or even Mexico.

Of course opiates are a big problem even in wealthy areas, which gets me to what “deaths of despair” would actually mean. I agree that the main cause of the epidemic is not economic hard times but the huge increase in the supply of the drugs. But why did people want them? Why was there, in economic terms, a huge unmet demand for opiates that changes in how doctors treat pain went a long way toward filling?

I don't think people take these drugs for fun. They take them because they are unhappy, stressed, and in pain. They are self-medicating conditions we could call anxious depression, chronic pain, chronic fatigue, or other such medical-sounding terms, but which I would be equally happy to call despair. I don't mean to say that many drug users don't have physical problems, from bad backs to chemical imbalances in their brains; I just think that when drug use runs rampant through whole communities, a broader understanding of the cause is called for.

If it is true that the main cause of the current opioid epidemic is increased supply, that makes the essential question very clear: why do people need drugs in the first place? And, is there anything we could do to make their lives better – less stressful, less painful, less depressing?

Opiates in New Hampshire, or, Things are Complicated

The number one state for opiate overdose deaths is West Virginia, which is relatively poor and troubled in other ways. The number two state is New Hampshire:

Which U.S. state had the highest median income in 2016? . . .

New Hampshire.

The Granite State’s median household income last year was a whopping $76,260, nearly 30 percent higher than the national median of $59,039, according to the Census. . . .

One of the chief drivers of New Hampshire’s high median income is its poverty rate, which is the lowest in the nation. Only 6.9 percent of the state’s residents live below the poverty line, compared with a national average of 13.7 percent (in Mississippi nearly 21 percent of people live in poverty).

New Hampshire’s workforce is also among the best-educated in the country, according to previously released census data. Better-educated workers tend to make more money.

New Hampshire also has low inequality.

Economic distress is not the only driver of the opiate crisis.

It might be relevant that low-tax New Hampshire has very little in the way of state-funded addiction help. But I think the fundamental point is that America's current crisis is not economic; economically we are doing ok. It is a crisis of spirit.

Overdose Deaths Still Rising in Ohio

In Ohio, overdose deaths rose 33% from 2015-2016, a staggering amount. Most are from the synthetic opiate Fentanyl or its close analogs.

This is the sort of problem we ought to be working on solving, instead of shouting insults at each other.

Stressed Workers

Here, from the National Survey on Drug Use and Health, are the key statistics on which workers are the heaviest users of alcohol and drugs. These were published in 2015, so this is the most recent fully analyzed data available:

• Combined data from 2008 to 2012 indicate that an annual average of 8.7 percent of full-time workers aged 18 to 64 used alcohol heavily in the past month, 8.6 percent used illicit drugs in the past month, and 9.5 percent were dependent on or abused alcohol or illicit drugs in the past year.
• The highest rates of past month heavy alcohol use among full-time workers aged 18 to 64 were found in the mining (17.5 percent) and construction industries (16.5 percent).
• The highest rates of past month illicit drug use were found in the accommodations and food services industry (19.1 percent).
• The workers in the accommodations and food services industry (16.9 percent) had the highest rates of past year substance use disorder.

I don't know any miners, but I can't say I am at all surprised to see construction workers and waiters at the top of the list.

Construction workers show up as having problems in lots of ways, partly because their employment is episodic: even highly skilled workers are regularly laid off for a while between projects, and some kinds of work can be shut down for weeks at a time due to the weather. So while they can earn a lot of money while they are working, they have trouble really moving into the middle class.

I wonder about the issues surrounding waiters, bartenders, and casino workers; is is the work, or is it that the work draws a certain sort of person, one who wants to work late hours around alcohol?

Marijuana in West Virginia

According to NORML, the biggest cash crop in West Virginia agriculture is marijuana, and has been for twenty years.

Now a group of young legislators is pushing for full legalization in the state, hoping that it would help with several of the state's pressing problems: the budget crunch, the lack of jobs, and especially the opiate epidemic. I'm not generally a fan of drugs, but if people on disability are determined to ease their woes with something, better cannabis than Oxycontin or whiskey. And there is evidence that it can work that way.

Last year the state passed a medical marijuana law, but it is so restrictive that it may not lead to much legal use.

I think full legalization is certainly worth trying, but then I've never thought marijuana should have been banned in the first place. Whether West Virginia's increasingly conservative legislature will ever see things that way is another question.

A Map of Opioid Prescriptions per Capita

Fascinating map from 538. (It's a big image, so click if you want more detail.) Notice two things: first, the opiate belt in southern Appalachia, that zone of increasing  immiseration. Second, all the major cities show up as low-prescription zones, from Boston to Miami to Los Angeles to Seattle. I wonder is that is because this really is a rural/exurban crisis, or if heroin is just more readily available in big cities.

Dutch Students and Weed

The latest study:

For decades, marijuana use and sale had been legal in the Netherlands and could even be purchased at coffee shops and cannabis shops around the region, which led to a massive increase in drug tourism — people coming to the Netherlands with the intention to purchase or use pot. In time, the city of Maastricht saw its crime rate triple compared with that of cities further from the border. To curb the drug tourism problem (mostly coming from, as the study authors write, “bad tourists” from France and Luxembourg), cannabis shop owners in 2011 issued a “partial prohibition” policy change, which only allowed people from specific nationalities to buy cannabis on their premises. Interested customers had to present a valid Dutch, German, or Belgian ID to be granted entry to a cannabis shop.

This policy created a unique situation, the study authors write, where students at the university could be separated into groups — those that could legally obtain marijuana and those that could not — and their academic performance could be measured. They concluded that students who could no longer legally buy cannabis increased their grades substantially — particularly in classes that required more math or numerical knowledge.

I can think of many problems with this study, the first of which is that foreign students in the Netherlands may well be particularly interested in legal weed, so they may not be the best group on which to perform such a study. But my general impression of my children's generation is that marijuana is considered among them the drug of slackers, avoided by kids with any ambition.

Jails as Drug Treatment Centers

As the nation's opiate epidemic continues to worsen – preliminary figures for 2016 show 59,000 overdose deaths nationwide, up 19% from 2015's record total – states are getting desperate for solutions. Some are trying approaches that would never have been considered a decade ago, for example Kentucky's experiment with installing full-fledged drug treatment centers in jails:

The sheer dimensions of the opiate-addiction epidemic are forcing new ideas. One of them, now being tried extensively in Kentucky, is jail not as a cost but as an investment in recovery. Jails as full-time rehab centers — from lights on to lights out.

Jailing addicts is anathema to treatment advocates. But as any parent of an addict can tell you, opiates are mind-controlling beasts. A kid who complained about the least little household chore while sober will, as an addict, walk through five miles of snow, endure any hardship or humiliation, to get his dope.

Waiting for an addict to reach rock bottom and make a rational choice to seek treatment sounds nice in theory. But it ignores the nature of the drugs in question, while also assuming a private treatment bed is miraculously available at the moment the addict, who is usually without insurance, is willing and financially able to occupy it. The reality is that, unlike with other drugs, with opiates rock bottom is often death. . . .

Jail may in fact be the best place to initiate addict recovery. It’s in jail where addicts first come face-to-face with the criminal-justice system, long before they commit crimes that warrant a prison sentence. Once in custody and detoxed of the dope that has controlled their decisions, it’s in jail where addicts more clearly behold the wreckage of their lives. And it is at that moment of clarity and contrition when they are typically plunged into a jailhouse of extortion, violence and tedium.

In the red state of Kentucky, a relentless opiate-addiction epidemic is changing long-held dogma about how to deal with addicts. Families who once supported a “throw away the key” approach to addiction are thinking differently now that their loved ones are strung out. Kentucky is also the only state that elects its jailers. This gives them more autonomy than their counterparts elsewhere. It also inspires more budgetary accountability to voters, and thus an acute awareness of the costs of cycling inmates in and out and back in again.

Kenton County is among the latest of two dozen Kentucky county jails that have started full-time “therapeutic communities” aimed at rehabilitation within their walls, providing inmates the services that private treatment centers offer on the outside. Much of the impetus has come from the state’s Department of Corrections, which a decade ago began transitioning its prisons away from pure lockups to providing drug treatment.

It will take years to find out how well this works, but meanwhile it certainly seems worth trying to me.

Opioid Lawsuits

The Attorney General of Ohio, Mike DeWine, has filed a huge lawsuit against five drug companies for their part in creating our opioid painkiller crisis. The suit accuses them of false advertising, both exaggerating the benefits of the drugs and minimizing the harm they cause:

The lawsuit cites several examples of misleading marketing: An Endo-sponsored website, PainKnowledge.com, in 2009 claimed that “people who take opioids as prescribed usually do not become addicted.” Janssen approved and distributed a patient education guide in 2009 that attempted to counter the “myth” that opioids are addictive, claiming that “many studies show that opioids are rarely addictive when used properly for the management of chronic pain.” Purdue sponsored a publication from the American Pain Foundation, which is heavily funded by opioid companies, claiming that the risk of addiction is less than 1 percent among children prescribed opioids — suggesting pain is undertreated and opioids are necessary.

This is only a small sampling. In total, DeWine claims opioid companies spent “millions of dollars on promotional activities and materials that falsely deny or trivialize the risks of opioids while overstating the benefits of using them for chronic pain.”

Meanwhile the Cherokee Nation has filed their own lawsuit against the distributors of these drugs, claiming that they have not fulfilled their obligation under Federal law to investigate doctors or clinics that issue unusually large numbers of prescriptions. I have read before about some doctors who got away for years with handing out pills like crazy, and the distributors absolutely have a legal obligation to do something about it. The Vox story cites a good example:

The small town of Kermit, West Virginia, has a population of 392, but a single pharmacy there received 9 million hydrocodone pills over two years from out-of-state drug companies.

In their defense the companies will cite the big movement that took off in the 1990s to treat pain more aggressively and argue that they were just responding to what doctors and patients wanted. We'll see; it seems to me that both of these legal avenues have a good chance of succeeding, and it would not surprise me at all if we end up in a few years with a gigantic tobacco company-style nationwide settlement.

Meanwhile many people who first got addicted to prescription pills have already moved on to heroin, which is cheaper, so even completely cutting off the supply will not solve the problem. But imposing more discipline on the prescription process seems like a good step.

Jihadi Pills

Since we were talking here back in September about the massive use of methamphetamines by the Nazi regime, I thought I should mention that the soldiers of the Islamic State have become notorious for constantly popping "jihadi pills." Their drug of choice is sometimes called Captagon. Captagon is a brand name of Fenethylline, a large molecule that breaks down into two separate amphetamines with slightly different effects. This used to be prescribed for hyperactivity in children and depression in adults, preferred to other amphetamines because it has less effect on the heart. However, government labs have studied the "Captagon" that one can buy on the black market and find that it is mostly generic amphetamines, and according to wikipedia most of what jihadis use is made in local labs and is therefore not likely to be Fenethylline either.

Anyway the soldiers fighting for the Islamic State are regularly pumped up on amphetamines, and I would not be surprised if that applies to many other combatants in the region. Some accounts from ex-jihadis speak of being given drugs that cause hallucinations, which would have to be something other than plain amphetamine; perhaps one of those cocktails of amphetamine and ketamine or ecstasy.

Explains a lot.