The ketamine analog methoxetamine: a new designer drug to threaten military readiness.

Recent years have seen the emergence and proliferation of "legal highs" or "designer drugs," compounds purposefully designed as legal alternatives to controlled substances of abuse. This article describes methoxetamine, a dissociative drug belonging to the arylcyclohexylamine class including phencyclidine and ketamine. Methoxetamine acts principally on the glutamatergic N-methyl-D-aspartate receptor and the serotonin receptor. It is sold as a white or off-white powder. Marketed as a "bladder friendly" alternative to ketamine, preliminary research suggests renal and cystic toxicity similar to ketamine. Methoxetamine is primarily ingested nasally, though also orally, intramuscularly, intravenously, and rectally. Users report dissociative features and, at higher doses, an "m-hole" experience akin to ketamine's "k-hole" described as extreme depersonalization and derealization. The 13 cases of acute methoxetamine toxicity described in the literature are summarized. The toxidrome consists of dissociation/delirium, sympathetic activation, and cerebellar symptoms. Methoxetamine is not detected in standard urine drug tests and there are no reliable laboratory findings. Management of acute methoxetamine toxicity is supportive, consisting of benzodiazepines, antiemetics, intravenous fluids, and respiratory support as indicated. Should methoxetamine conform to the observed 2-year lag of designer drugs migrating from Europe to the United States usage may increase in early 2014.