The Paradox of Phencyclidine (PCP) Abuse PHENCYCLIDINE, widely abbreviated as PCP, and known by street names such as "angel dust," "goon," and dozens of others, is a deeply disturbing drug, dangerous both in acute and chronic use. It has been said to be everything we were afraid marihuana would turn out to be but hasn't. Among abused drugs, it has no current rivals for a whole litany of disturbing effects: Accidental high doses can produce severe or fatal medical complications, acute and recurrent psychoses, suicidal depressions, and unpredictable violence. Chronic use brings aggressiveness, psychologic dependence, memory loss, and physiologic dependence. Tragically, its use is widespread among young adolescents. Phencyclidine was originally developed and marketed as an anesthetic, but withdrawn because of a large number of adverse side-effects, including postanesthetic psychosis. It is easy to manufacture clandestinely, and numerous active variants of the basic compound are also psychoactive. In 1978 the National Institute on Drug Abuse (NIDA) convened an assembly of researchers of this drug. The consensus was that PCP was, if anything, a more disturbing drug than had been previously recognized. Though it was generally agreed that severe consequences might not befall every user, the list of disasters that frequently accompany the use of phencyclidine was of deep concern. Because it is frequently sold to naive users as other more sought-after drugs, and because it has so many "aliases," any estimates of PCP use based on survey statistics undoubtedly understate the extent of use. Nevertheless they are valuable in indicating trends. Use markedly increased during the most recent two-year period for which we have National Survey data. Most disturbingly, among youths from ages 12 to 17, the number of users nearly doubled from 1976 to 1977 (from 3.0% to 5.8%) ( N I D A National Survey). Among young adults from 18 to 25 years old, the peak years for all illicit drug use, an increase of nearly 50% occurred (from 9.5% in 1976 to 13.9% in 1977) in the number of those reporting having ever used PCP. Two other sources that help gauge the seriousness of the PCP epidemic are the U.S. Drug Abuse Warning 428
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Network ( D A W N ) and the National Youth Polydrug Study (NYPS). The D A W N network showed that the number of PCP-related emergencies and deaths doubled in the two years from 1974 to 1976 (from 54 to 111). The NYPS, consisting of reports from 97 drug-abuse treatment programs, showed nearly a third of youthful drug users (2750 users younger than age 19) having used PCP. Their use of PCP exceeded that of inhalants, sedatives, cocaine, and opiates; and fully two thirds of those who had ever tried PCP were regular users. Other indicators, such as the number of illicit PCP laboratories discovered and the number of arrests involving PCP, have all gone up correspondingly, providing converging lines of evidence that PCP use has markedly increased. Currently, the most popular form of self-administration of PCP is by smoking phencyclidine hydrochloride, which is the common street form of phencyclidine. The drug is usually inhaled from a cigarette of parsley, tobacco, or marihuana that has been "dusted" with powdered PCP. Other modes of ingestion are used: oral (harder for the user to regulate dose and effects), snorting, and intravenous injection (least common, but not at all rare). Phencyclidine is acknowledged by many of its users to be an unpredictable, dangerous drug. Street knowledge fairly accurately reflects the potential acute and longterm dangers of this drug. Fauman and Fauman (1) report that 76% of their sample of users acknowledged having had "bad trips," and many reported deterioration of intellectual abilities and personality. Despite these well-known dangers, many users prefer PCP to all other drugs. In manageable doses, it can produce a variety of desirable feelings. Perceptual distortions are frequent and enjoyable. Pleasant feelings of numbness and dissociation unfold, accompanied by a welcome freedom from care and dissolving of tensions and anxiety (hence the term, PeaCe Pill) (2, 3). A group of Hawaiian users described it enthusiastically as "like surfing all day" (4). Pleasant feelings of dissociation are frequently reported. Phencyclidine is a hallucinogen that many users prize for enabling them to reach a state of consciousness not attainable through lysergic acid diethylamide. Of
course, all these feelings differ greatly among users (5). Many users are also attracted to the drug because it is extremely easy to obtain and conceal, and because some degree of titration of its effects is possible if the appropriate route of administration is chosen. Neither can an element of bravado be discounted in accounting for the appeal of a drug known to its users as "embalming fluid," "killer weed," and "cyclones." Users are introduced to PCP largely by friends; the drug itself is used almost entirely socially rather than alone. The uncomplicated effects of a single smoked dose may last from 4 to 6 hours, followed by a "coming down" period. With continued use, some degree of tolerance develops, with increasing doses being required to create the same effects. Phencyclidine can have undesirable effects that are quite hard for the user to anticipate either in first use or after sustained use. These unpleasant effects often occur because he is using unknown quantities (6). The overdose symptoms described elsewhere in this issue in the review by Khantzian and McKenna, pp. 361-372 (7), are strongly dose related. Less clearly a function of dose alone are the bad trips that consist of various effects: intolerable numbness, paralysis, hallucinations, anxiety, feelings of irreversible dissociation and impending death, paranoia, and outbursts of violent behavior. Psychotic reactions, which may last for days and weeks, are often confused with acute schizophrenia when seen in the emergency room. Prolonged psychotic reactions occur with only a minority of users, perhaps only in a group that has special vulnerability to this effect of the drug, but this minority can account for a remarkable number of hospital admissions. In a series of 15 patients hospitalized with PCP psychoses, Yesavage and Freman (8) found that no smoker of PCP required longer than three days' hospitalization, whereas oral ingestors required at least four days' hospitalization. Length of hospital stay was also correlated with urine PCP concentrations. During their confusion, some users commit bizarre acts of violence, mutilating their victims in a manner suggesting a psychotic state. Experiencing the anesthesia that is a primary effect of the drug, users may feel invulnerable, and have attacked several policemen singlehanded and unarmed, and even, on occasion, unclothed. The medical complications of an overdose of PCP are potentially fatal and must be dealt with in a wellequipped intensive care unit. These are set forth on pp. 368-369 by Khantzian and McKenna (7). The effects of chronic PCP use appear to be quite as worrisome as the acute effects, although only the most preliminary work has been done yet to assess their incidence and severity. Although many chronic users are able to avoid troubles during their initial period of use, the incidence of adverse effects rises as use persists. Some tolerance appears to develop, resulting in the need for substantially higher daily doses for the same effect. Memory loss is frequent and can persist for months after discontinuing the drug. Other frequent problems include chronic fatigue, persistent irritability, and severe depres-
sion. Many users reported losing interest in social activities, while alienating their friends as a result of these personality and mood changes. (Increased belligerence and violence is also frequently found in patients with organic brain disorders, and Fauman and Fauman [9] suggest that chronic use of PCP does, in fact, produce an organic brain disorder.) Phencyclidine does not appear to be addicting: that is, withdrawal symptoms do not appear if its use is suddenly stopped. However, it creates strong dependence; users often carry it with them to be sure they are never without it. Some tolerance appears to develop; chronic users ingest considerably more per occasion than occasional users. The treatment of the chronic user is supportive, offering the greatest possibility for developing a lifestyle free of this and other drugs. But it is important to remember that PCP use is accompanied by considerable abuse of other drugs. The PCP-using drug users in the NYPS study used twice as many other drugs as non-PCP drug users, and there was not a single case of exclusive PCP use. For these youths, PCP use is an integral part of a larger polydrug abuse problem that must be dealt with in therapy. The results of treatment so far have not been encouraging, for PCP is powerful, satisfying, inexpensive, and readily available. The PCP user is, first of all, a polydrug user. Phencyclidine is rarely the first drug with which experimentation begins; it usually follows the use of alcohol, marihuana, sedatives, stimulants, and sometimes opiates. It is particularly disturbing to know that the average age at onset of use is 14. Several authors have commented on the pervasive anger and alienation of youths who are attracted to the drug (4). Although its use is certainly common among disadvantaged youths, it is also used by the affluent and well educated, with Caucasians over-represented, if anything, in several samples of PCP users. The enthusiasm with which many have taken up the use of PCP, despite ample second-hand (and often firsthand) knowledge of its unpredictable capacity for permanent damage, reminds us that much illicit drug use is neither rational nor well understood (10). Hovering in the background may be, for all we know, another drug even more dangerous than PCP, waiting to emerge as a new drug of choice for thousands of users. In the short run, PCP is the clear and present danger; in the long run, the danger is our ignorance of what motivates the drug abuser. ( R I C H A R D
STILLMAN,
PETERSEN, PH.D.; National Rockville, Maryland)
M.D.;
Institute
and
ROBERT
on Drug
References 1. FAUMAN MA, FAUMAN BJ: The psychiatric aspects of chronic phencyclidine use: a study of chronic PCP users, in Phencyclidine (PCP) Abuse: An Appraisal, edited by PETERSEN R, STILLMAN R. Washington, U.S. Government Printing Office, 1978 pp. 183-200 2. SIEGEL RK: Phencyclidine and ketamine intoxication: a study of four populations of recreational users. See Reference 1, pp. 119-147 3. BURNS RS, LERNER SE: Perspectives: acute phencyclidine intoxication. Clin Toxicol 9:477-501, 1976 4. MARSELLA AJ, HICKS RD: Phenomenological aspects of phencyclidine abuse among ethnic groups in Hawaii. See Reference 1, pp. 201-209 5. POLLARD JC, U H R L, STERN E (ed): Drugs and Phantasy: The Effects Editorials
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C.
Abuse;
429
of LSD, Psilocybin and Sernyl on College Students. Boston, Little, Brown and Co., 1965 6. RAINEY JM, C R O W D E R MK: Prevalence of phencyclidine in street drug preparations. N Engl J Med 290:466-467, 1974 7. K H A N T Z I A N WJ, M C K E N N A GJ: Acute toxic and withdrawal reactions associated with drug use and abuse. Ann Intern Med 90:361-372, 1979 8. YESAVAGE J A, F R E M A N AM: Acute phencyclidine intoxication: psy-
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chopathology and prognosis. / Clin Psychol 37:664-666, 1978 9. FAUMAN MA, FAUMAN BS: The differential diagnosis of organic based psychiatric disturbance in the emergency department. / Am Coll Emergency Physicians 6:315-323, 1977 10. M E L L O NK: Control of drug administration: The role of aversive consequences. See Reference 1, pp. 289-308
March 1979 • Annals of Internal Medicine • Volume 90 • Number 3
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Network ( D A W N ) and the National Youth Polydrug Study (NYPS). The D A W N network showed that the number of PCP-related emergencies and deaths doubled in the two years from 1974 to 1976 (from 54 to 111). The NYPS, consisting of reports from 97 drug-abuse treatment programs, showed nearly a third of youthful drug users (2750 users younger than age 19) having used PCP. Their use of PCP exceeded that of inhalants, sedatives, cocaine, and opiates; and fully two thirds of those who had ever tried PCP were regular users. Other indicators, such as the number of illicit PCP laboratories discovered and the number of arrests involving PCP, have all gone up correspondingly, providing converging lines of evidence that PCP use has markedly increased. Currently, the most popular form of self-administration of PCP is by smoking phencyclidine hydrochloride, which is the common street form of phencyclidine. The drug is usually inhaled from a cigarette of parsley, tobacco, or marihuana that has been "dusted" with powdered PCP. Other modes of ingestion are used: oral (harder for the user to regulate dose and effects), snorting, and intravenous injection (least common, but not at all rare). Phencyclidine is acknowledged by many of its users to be an unpredictable, dangerous drug. Street knowledge fairly accurately reflects the potential acute and longterm dangers of this drug. Fauman and Fauman (1) report that 76% of their sample of users acknowledged having had "bad trips," and many reported deterioration of intellectual abilities and personality. Despite these well-known dangers, many users prefer PCP to all other drugs. In manageable doses, it can produce a variety of desirable feelings. Perceptual distortions are frequent and enjoyable. Pleasant feelings of numbness and dissociation unfold, accompanied by a welcome freedom from care and dissolving of tensions and anxiety (hence the term, PeaCe Pill) (2, 3). A group of Hawaiian users described it enthusiastically as "like surfing all day" (4). Pleasant feelings of dissociation are frequently reported. Phencyclidine is a hallucinogen that many users prize for enabling them to reach a state of consciousness not attainable through lysergic acid diethylamide. Of
course, all these feelings differ greatly among users (5). Many users are also attracted to the drug because it is extremely easy to obtain and conceal, and because some degree of titration of its effects is possible if the appropriate route of administration is chosen. Neither can an element of bravado be discounted in accounting for the appeal of a drug known to its users as "embalming fluid," "killer weed," and "cyclones." Users are introduced to PCP largely by friends; the drug itself is used almost entirely socially rather than alone. The uncomplicated effects of a single smoked dose may last from 4 to 6 hours, followed by a "coming down" period. With continued use, some degree of tolerance develops, with increasing doses being required to create the same effects. Phencyclidine can have undesirable effects that are quite hard for the user to anticipate either in first use or after sustained use. These unpleasant effects often occur because he is using unknown quantities (6). The overdose symptoms described elsewhere in this issue in the review by Khantzian and McKenna, pp. 361-372 (7), are strongly dose related. Less clearly a function of dose alone are the bad trips that consist of various effects: intolerable numbness, paralysis, hallucinations, anxiety, feelings of irreversible dissociation and impending death, paranoia, and outbursts of violent behavior. Psychotic reactions, which may last for days and weeks, are often confused with acute schizophrenia when seen in the emergency room. Prolonged psychotic reactions occur with only a minority of users, perhaps only in a group that has special vulnerability to this effect of the drug, but this minority can account for a remarkable number of hospital admissions. In a series of 15 patients hospitalized with PCP psychoses, Yesavage and Freman (8) found that no smoker of PCP required longer than three days' hospitalization, whereas oral ingestors required at least four days' hospitalization. Length of hospital stay was also correlated with urine PCP concentrations. During their confusion, some users commit bizarre acts of violence, mutilating their victims in a manner suggesting a psychotic state. Experiencing the anesthesia that is a primary effect of the drug, users may feel invulnerable, and have attacked several policemen singlehanded and unarmed, and even, on occasion, unclothed. The medical complications of an overdose of PCP are potentially fatal and must be dealt with in a wellequipped intensive care unit. These are set forth on pp. 368-369 by Khantzian and McKenna (7). The effects of chronic PCP use appear to be quite as worrisome as the acute effects, although only the most preliminary work has been done yet to assess their incidence and severity. Although many chronic users are able to avoid troubles during their initial period of use, the incidence of adverse effects rises as use persists. Some tolerance appears to develop, resulting in the need for substantially higher daily doses for the same effect. Memory loss is frequent and can persist for months after discontinuing the drug. Other frequent problems include chronic fatigue, persistent irritability, and severe depres-
sion. Many users reported losing interest in social activities, while alienating their friends as a result of these personality and mood changes. (Increased belligerence and violence is also frequently found in patients with organic brain disorders, and Fauman and Fauman [9] suggest that chronic use of PCP does, in fact, produce an organic brain disorder.) Phencyclidine does not appear to be addicting: that is, withdrawal symptoms do not appear if its use is suddenly stopped. However, it creates strong dependence; users often carry it with them to be sure they are never without it. Some tolerance appears to develop; chronic users ingest considerably more per occasion than occasional users. The treatment of the chronic user is supportive, offering the greatest possibility for developing a lifestyle free of this and other drugs. But it is important to remember that PCP use is accompanied by considerable abuse of other drugs. The PCP-using drug users in the NYPS study used twice as many other drugs as non-PCP drug users, and there was not a single case of exclusive PCP use. For these youths, PCP use is an integral part of a larger polydrug abuse problem that must be dealt with in therapy. The results of treatment so far have not been encouraging, for PCP is powerful, satisfying, inexpensive, and readily available. The PCP user is, first of all, a polydrug user. Phencyclidine is rarely the first drug with which experimentation begins; it usually follows the use of alcohol, marihuana, sedatives, stimulants, and sometimes opiates. It is particularly disturbing to know that the average age at onset of use is 14. Several authors have commented on the pervasive anger and alienation of youths who are attracted to the drug (4). Although its use is certainly common among disadvantaged youths, it is also used by the affluent and well educated, with Caucasians over-represented, if anything, in several samples of PCP users. The enthusiasm with which many have taken up the use of PCP, despite ample second-hand (and often firsthand) knowledge of its unpredictable capacity for permanent damage, reminds us that much illicit drug use is neither rational nor well understood (10). Hovering in the background may be, for all we know, another drug even more dangerous than PCP, waiting to emerge as a new drug of choice for thousands of users. In the short run, PCP is the clear and present danger; in the long run, the danger is our ignorance of what motivates the drug abuser. ( R I C H A R D
STILLMAN,
PETERSEN, PH.D.; National Rockville, Maryland)
M.D.;
Institute
and
ROBERT
on Drug
References 1. FAUMAN MA, FAUMAN BJ: The psychiatric aspects of chronic phencyclidine use: a study of chronic PCP users, in Phencyclidine (PCP) Abuse: An Appraisal, edited by PETERSEN R, STILLMAN R. Washington, U.S. Government Printing Office, 1978 pp. 183-200 2. SIEGEL RK: Phencyclidine and ketamine intoxication: a study of four populations of recreational users. See Reference 1, pp. 119-147 3. BURNS RS, LERNER SE: Perspectives: acute phencyclidine intoxication. Clin Toxicol 9:477-501, 1976 4. MARSELLA AJ, HICKS RD: Phenomenological aspects of phencyclidine abuse among ethnic groups in Hawaii. See Reference 1, pp. 201-209 5. POLLARD JC, U H R L, STERN E (ed): Drugs and Phantasy: The Effects Editorials
Downloaded from https://annals.org by Duke Medical Library user on 01/10/2019
C.
Abuse;
429
of LSD, Psilocybin and Sernyl on College Students. Boston, Little, Brown and Co., 1965 6. RAINEY JM, C R O W D E R MK: Prevalence of phencyclidine in street drug preparations. N Engl J Med 290:466-467, 1974 7. K H A N T Z I A N WJ, M C K E N N A GJ: Acute toxic and withdrawal reactions associated with drug use and abuse. Ann Intern Med 90:361-372, 1979 8. YESAVAGE J A, F R E M A N AM: Acute phencyclidine intoxication: psy-
4 3 0
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chopathology and prognosis. / Clin Psychol 37:664-666, 1978 9. FAUMAN MA, FAUMAN BS: The differential diagnosis of organic based psychiatric disturbance in the emergency department. / Am Coll Emergency Physicians 6:315-323, 1977 10. M E L L O NK: Control of drug administration: The role of aversive consequences. See Reference 1, pp. 289-308
