Emilio Salgado, clinical toxicologist: ‘Methamphetamine is really dangerous, more so than cocaine’

The doctor at the Hospital Clínic de Barcelona warns that this substance, used in ‘chemsex’, can cause very serious neuropsychiatric alterations in a very short time

Emilio Salgado
Emilio Salgado, head of the Toxicology Unit of the Hospital Clínic de Barcelona, Spain.massimiliano minocri
Jessica Mouzo

More than 2,000 people with acute poisoning have come through the emergency door of the Hospital Clínic de Barcelona (Spain) this year. Alcohol, cocaine, cannabis, medications, and even cleaning products can be the culprits, explains Emilio Salgado, head of the Clinical Toxicology Unit attached to the emergency area of the hospital. “Basically, what we see in the emergency room is acute poisoning. Around 60% are usually due to drug abuse and present with symptoms such as decreased level of consciousness or, quite the opposite: a person who is hyper-excited, in psychomotor agitation as a consequence of drug use,” says Salgado. There are also poisonings due to attempted suicide or accidental symptoms caused by bleaches or detergents.

In a recent analysis by the unit at Hospital Clínic, alcohol is still the most common drug behind acute poisonings, but, with respect to 2022, cocaine, amphetamines, and ketamine, among others, are gaining ground. Salgado warns that what arrives at the emergency room is “the tip of the iceberg” of what is cooked on the street, and what causes the most poisoning is not always what is consumed the most; but he admits that the Toxicology Unit does function, in practice, as a gauge of new phenomena. “We act as an early warning center,” says the doctor, who actively searches for emerging substances on the market and has detected new consumption patterns.

Question. In your analysis you report about 15 deaths this year, more than one death per month on average. What does this data mean?

Answer. The phenomenon of acute poisoning is rare. That is, of all the cases treated each year in the emergency department of the Hospital Clínic, 2.5% are due to acute poisoning, and the likelihood of dying is 0.4%. It is true that this year we have seen a significant increase in the number of deaths and roughly speaking, half of them were from drug abuse and half from attempted suicide by drug overdose. We’ll have to see how the trend goes. For example, regarding the particularities of drug consumption in Barcelona, we are in a situation in which there is more supply than demand for cocaine, which for me personally worries me the most from a public health point of view. Currently, Europeans have surpassed the United States as the number one consumers of cocaine in the world, and this implies a very significant change in the market. There is so much of the drug on the street, that one is able to buy even good quality cocaine at a reduced price. And this has never been seen before. The usual thing was the opposite: there was little supply, prices rose, and cocaine became more adulterated.

Q. You say that cocaine is the drug that worries you the most. Why?

A. First of all, cocaine worries me because of the number of people who use it. And its effect is stimulating, it produces an adrenergic discharge of the excitatory neurotransmitters of the central nervous system, which causes an impressive high. From an acute point of view, it can be very dangerous because the rise in these excitatory neurotransmitters can cause increased blood pressure, tachycardia, cardiac arrhythmias, and even death. They can also cause the coronary arteries to close and users suffer a myocardial infarction, cardiac arrhythmia, and death. It can also cause an imbalance between temperature production and heat loss: if a person does cocaine, heat loss is compromised and in the end they suffer from hyperthermia, and when their core temperature goes above 107 ºF, the proteins denature and the person melts inside. From a chronic point of view, we must also view cocaine in the same way any other cardiovascular risk factor.

Q. Is cocaine abuse trivilaized?

A. Those who use cocaine do it primarily for the high, but then they have to pay a price. Not only do users have cardiovascular alterations, but they also have a very important alteration from the cerebral point of view — in terms of addiction — continually thinking about when they are going to use again. The trivialization of drug consumption is there. The most obvious example is cannabis.

Q. How does cannabis poisoning present at the emergency room door?

A. It is the most consumed illegal substance in our area. But, despite there being so many consumers, they rarely appear in the emergency room. It’s difficult to end up in the emergency room just from cannabis. Lately, what we are seeing more and more is oral cannabis poisoning from cannabis cookies. Although it is poorly absorbed, when you get the bud, you get the whole amount that is there. It is absorbed by your small intestine and poisoning occurs.

Q. In the case of alcohol, has the consumption pattern changed?

A. The Mediterranean drinking pattern, such as having a glass of wine with food, is in danger of extinction. Now, what is going to prevail more and more is bingedrinking: consuming the greatest amount of alcohol possible in the shortest possible time to get drunk. This is how young people under 20 years old drink now.

Q. Does drug poisoning have more to do with taking too much, mixing drugs, or the fact that you don’t know what you’re taking and everything is adulterated?

A. Mixing drugs is the most common way to end up in the emergency room and this involves alcohol, cannabis, and cocaine. But the role of cannabis here would be minor and what really gives you the symptoms is alcohol and cocaine. As for the problems that adulteration can cause, they are there, above all, with amphetamine derivatives. The market for abused substances is in flux. Every year there are new substances that enter the market and, perhaps, within 20 years, consumption patterns will change. We are seeing this lately with the very significant increase in consumption of the so-called pink cocaine or tusi. And users might think that what they are buying from the dealer is an amphetamine derivative called 2C-B, but no: those who buy pink cocaine buy ketamine, which is a hallucinogenic substance and a fundamentally dissociative anesthetic drug, mixed with MDMA and, sometimes caffeine. And we know this because we have a toxicology laboratory that can detect all of these substances. We act as an early warning center.

Emilio Salgado
Emilio Salgado, head of the Toxicology Unit at the Hospital Clínic of Barcelona.massimiliano minocri

Q. Are there many new drugs coming in?

A. In the case of ketamine, it is a revival. Chronic ketamine use has very significant adverse effects, such as very acute abdominal pain and hemorrhagic cystitis. Now the problem is that ketamine is being used for the treatment of drug-resistant depression, and when you put a substance on the market, you facilitate the increase of its availability. We are seeing it within the so-called pink cocaine. As an upward trend, I see ketamine. We are seeing an increase and we just have to give its chronic effects time because it also has a very significant addiction potential.

Q. Are you seeing other consumption patterns in substance abuse?

A. Yes, in so-called chemsex, whose purpose is not to use the substances to get high, but to maintain group sexual relations for as long as possible, fundamentally between men who have sex with other men. And to do this they need very powerful stimulants, such as cocaine and MDMA. But since MDMA has hallucinogenic potential, they do not use it. They need other substances such as methamphetamine, which is really dangerous, perhaps more than cocaine itself because it will cause very serious alterations, from a neuropsychiatric point of view, in a short time. Anyone using the drug two or three times a week will start to have psychotic behaviors after a few months of using and, as use continues, the person can trigger a chronic psychiatric disorder. We are already seeing it. And we are treating cases of abuse of completely synthetic drugs, such as mephedrone and other cathinones. Even now we have 24 cases in the laboratory of a substance that cannot be identified because it is not in our library. It is a molecule that has not been described, so we cannot say what it is.

Q. How concerned are you about the phenomenon of chemsex in the impact of poisoning?

A. It is a problem with many aspects. From a consumption point of view, we are talking about substances whose acute and long-term effects we do not know and which can be potentially more lethal than any other substance we have seen so far. It is a situation that may also be very dangerous from the point of view of addiction. Now, in this context, what is most worrying is methamphetamine, because it causes psychotic episodes.

Q. Health authorities have shown that they fear a rise in the use of this substance.

A. We are not detecting an overall increase in methamphetamine use. In our field, it is very typical of chemsex. It all goes together: GHB, methamphetamine, Viagra, poppers. Information and prevention of harm must be focused on users of those drugs. It is very unlikely that methamphetamine abuse will become mainstream here. In Spain what people abuse is cocaine. In the population of Filipino or Thai origin, they also use methamphetamine as a stimulant, to endure hours and hours of work in very harsh conditions.

Q. In the United States there is a huge health crisis with fentanyl and other opioids. Leaving aside the distance, is something similar beginning to be seen in Spain, or could something similar happen?

A. It is an issue that concerns us all, but we must be cautious and understand the history of why what happened in the United States happened. In our area, two things are happening: on the one hand, we have the stigma of the opioid user that has carried over from the heroin era, and the other thing is the ultra-strict control on the prescription and distribution of this medication in our country. At the very least, we must be cautious in saying that this is going to be a debacle, as has happened in the United States.

Q. Are you worried that new generations will lose their fear of the historical stigma of opioids and dabble with these substances?

A. Well, there’s always the possibility that it could happen. But you become intoxicated with what you have available, and as long as there is ultra-strict control of opioids from a health point of view, as there is, I don’t think it will happen. There may be some dealing, and people who get addicted to fentanyl, but because they work among or with the drug. But I am actively looking for the average person and, to date, I have not found any cases.

Q. In the face of the global impact on health, which substance worries you the most?

A. Regarding the future impact, I am basically concerned about cocaine and the growth in the number of users it may have. Basically, because it is increasing: there is more supply and more demand. And then also, obviously, the other substance that I’m concerned about evolving over the next few years is ketamine and its chronic effects.

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