College Students with Mental Health Issues Can Get Help

Working with children and adolescents I have had many parents ask about 504 plans and Individual Educational Plans (IEP).  Parents tend to focus on the assistance their child may need in elementary or high school due to a learning disability or mental health issues.  From my 20 years experience as a psychotherapist, what I have seen is that if a child need assistance in elementary and high school, they typically need assistance in college. 

From my experience, most families assume there is no assistance in college.  However, typically if a child has an IEP, they are also entitled to assistance in college.  Most colleges in their Counseling departments have programs designed to help disabled students.  A student with a physical or learning disability or mental health issue such as ADHD or depression would qualify for assistance by the Disabled Students Program at a college.

Also if you live in California and you have a physical or learning disability or a mental health issue and had an IEP while in school, you may qualify to be a client of the California Department of Rehabilitation.  This Department is responsible for assisting people in California  ,with a disability, find a job and get the education they may need to find a job.  The Department may assist their clients by providing tuition assistance for community or state colleges and provide financial assistance to buy text books and school supplies.  What they are able to do depends on the State budget.

This is another reason for parents to insist when their child does need an IEP that the school district places the child on an IEP.  The lies schools tell parents that an IEP will prevent their child from getting into a college, the military or getting a job is not true.  Another reason to insist on the IEP, if your child qualifies for an IEP, is because your child can be granted accommodations on the SAT or ACT that students need to take when they apply for college.  I have had many teens with ADHD come to me seeking accommodations on the SAT or ACT.  A common requirement that the testing boards require is that a student needs to have had an IEP if they are seeking accommodations on these tests.

Therefore, many students who have disabilities or mental health issues can receive assistance in college.  While many people may be surprised, it is true.  However, for many college students finding the assistance can be confusing and overwhelming. For a Freshman in college dealing with heath or mental health issues the confusion and embarrassment people deal with because of society stereotypes can cause students to give up.  However, I was contacted by bettercollege.com with a resource guide they developed for college students with mental health issues.  While their guide was created for students with mental health issues, it can also be used as a guide for students with physical or learning disabilities.

Since I feel this is a valuable guide to Freshman students and their families, I am including a link to this resource guide below:

Guide to College Planning for Psychiatrically Impaired Students - https://www.bestcolleges.com/resources/college-planning-with-psychiatric-disabilities/

Dr. Michael Rubino is a psychotherapist with over 20 years experience working with children, teenagers and college students.  For more information about Dr. Rubino’s work and private practice visit one of his web sites www.RubinoCounseling.com or www.rcs-ca.com or his Facebook page www.Facebook.com/drrubino3.     

Accepting Your Child For Who They Are

As a psychotherapist who treats children and teenagers, I often work with children with attention difficulties and are oppositional.  These children having many difficulties at school, at home and with friends.  One of the primary difficulties in their lives is their relationship with their parents. Many parents tell me they love their child with these issues, but accepting it is very difficult.  They even admit loving the child at times is difficult.  This creates a great deal of guilt for these parents. It also creates more difficulties for the child because they can sense their parents feelings.

Every child wants to feel accepted by their parents and loved by their parents.  Children who do not feel loved or accepted will do almost anything to feel accepted. Disney’s movie Frozen mentions a number of times how important it is to feel loved and accepted.

Empowering Parents recently published an article by Anna Stewart.  Anna is a parent with a difficult child and explained these feelings very well.  So well that I am using part of her article below.  I am doing so because I believe it will help many parents with a difficult child who are feeling guilty about their reactions to their child.  Also I believe she offers good idea to improve the parent-child relationship so both parent and child feel loved and accept each other.

I was in love with my baby before I ever met him. And when I first held him, my whole body flooded with love. He was an easy baby as long as he was with me, but any time I tried to do something without him, he cried. I thought it was a sign of his affection for me.

Then he learned to walk and talk and express his opinions. Danny protested when we started looking at preschools. He asked me why I would send him away. I assumed he would enjoy kindergarten like I did, but he didn’t. His distaste for school got stronger, along with his resistant attitude. By the time he was in fourth grade, he outright refused to do homework. He was rude to his teachers, got other kids riled up and left a trail of debris wherever he went. I loved my son, but it was hard to accept him and his behaviors.

Every parent I have met loves their kids. While they have different ways of expressing their love, they all say they feel love—they just know they do. But like me, they may not accept who their child is, or what they care about, believe in or value. It’s not easy to love and accept a child who is different than you are or who doesn’t appear to fit in or who has behaviors that are hard to be around.  We want our love to be enough, but the truth is, without acceptance, it usually isn’t enough for our children. They know the difference between love and acceptance.

Though I couldn’t see it at the time, my son picked up on my disappointment in him. Where he once could find sanctuary with me at home, my anger at his behavior meant he no longer had a safe and loving place to learn how to find his own peace.

Instead, his teachers and I looked for a way to explain his “issues.”  We put him through a special education evaluation. I took him to a psychiatrist who gave him a list of labels: ADHD, ODD, mood disorder and anxiety, and he was then prescribed mood-altering medication. Danny knew he was not always in control of his behaviors, but he hated the medications, the labels and the look in the eyes of the adults around him. He could feel the judgment. He was internalizing the label of being broken, worthless, and unlikable. Not surprising, this made him fulfill what he felt and his actions got worse.

After weeks of forcing him out of the car, locking the doors and driving away while he raged in front of his classroom, I knew something had to change. And that something was me.

Danny was doing the only thing he knew how to do, so it was up to me to change my words, my actions and my way of showing him I loved and accepted him. The question was, did I accept him? I knew I hated his behavior; I felt ashamed of it and often ashamed and disappointed in him.

Danny’s brain worked differently than most of his classmates. He learned by doing, not reading. His creativity came through when he was given the time he needed to examine all the angles. His sharp mind and quick wit needed to be expressed, but not on a math worksheet. Danny had ADHD, and to him that meant he felt like a failure. He knew the people around him were unhappy with him. He could feel our grief. He could feel that we wanted to change him and that we did not like who he was, not just how he behaved. He felt broken. Danny did not feel loved and he did not feel accepted.

Many, many of our sons and daughters who live with differences such as ADHD, learning disabilities or anxiety, know that the world does not want them the way they are. The world sees them as defective, in need of remediation and simply not acceptable.

Thankfully, more adults with brain differences are sharing their stories. They are speaking out about what it is like to grow up never being good enough. One young man said, “Ican put up with my own hardships okay, but the thought that my life is the source of other people’s unhappiness, that’s plain unbearable.”

Another said, “School was hard, home was hard. I was stressed about everything all the time. I knew I was different and I know my parents and my teachers didn’t like me. And I didn’t like myself.”

That was my son. He couldn’t tell me that’s how he felt when he was in elementary and middle school. He simply did not know how to talk about it. I didn’t either. But I knew that I had to stop trying to “fix” Danny. He wasn’t broken, defective or disabled. He had so many strengths; but we had all lost sight of what those were because they were hidden in his anger, defiance, worry and sadness.

Here is one big piece that many parents face—our children’s differences are not ones we can relate to, so we are not prepared to both love and accept them.

I did not grow up with ADHD. I only heard about it after I became Danny’s mom. Modern parents who did grow up with ADHD often did not get diagnosed or get help until they were adults, so when they see their child struggle, they are helpless, just like they were as children. We merge our children’s conditions with their identities and label them disabled.

Now, more teens and adults are merging their conditions with their identities and labelling them “neurodiverse.” Offered a way to fix their challenges, they are saying, “No thank you, this is me.” Dr. Ned Hallowell, one of the leaders in ADHD, has the diagnoses of ADHD and dyslexia. He loves what he calls his “Ferrari brain” and does not want it taken away. He does want some of his symptoms to be better-managed, which he does through a comprehensive approach of natural and medical interventions. He has learned to accept and value his neurodivergence.

So how to I accept my son? How do I reconcile the boy I thought I wanted with the one I have? If I love him but don’taccept him, can he love and accept himself?

First I had to ask myself if I could accept the fact that I was a mother of a child who was different than his classmates. Could I live with the image of me as a parent of a child with a disability?  Or was it that I was afraid of my own beliefs—that Danny was inferior, that he would be dependent, that he couldn’t make it?

I started to listen to Danny. We tested him but did not agree to have him receive special education services: he was angry, not disabled. He asked to stop taking medication, and since we could not see any measurable benefit, we agreed. That also gave him the beginning of some control in his life. (This was our personal decision, and not a judgment. Every parent has to make this decision based on their own child and family.)

Danny’s seventh grade team of teachers asked us to meet with them. They sat in a circle and took turns telling him that he was blowing it. They could see he was smart, capable, charming, and creative but his classroom behaviors, refusal to do any school work and escalating physical altercations with other boys were derailing him. It was the most brutal meeting I have ever attended. I was hurt and angry that others would not accept him. But in Danny’s case, it was tough love and it worked.

Danny could see, even if I couldn’t, that his choices were indeed his choices and they were not getting him anywhere he wanted to be. He could also see that one teacher in particular was a true ally—though he tried to push her away, she wouldn’t go.

I think Danny realized that he was loved and accepted by me at home and by Mrs. K at school. His armor of attitude, anger and defiance started to crack. That let in some light in three main ways:

Change our words:

I started to say things to Danny that showed I valued his uniqueness. I would admire his ability to remember with great detail, the fishing trip where we caught a barracuda (which he did not eat but was eager to have us eat!)

He began to accept that his brain was wired differently. It wasn’t broken but different. That allowed him to start seeing the strengths he had in his ADHD brain, and not just the weaknesses. He started to accept help. The first thing he and Mrs. K did was clean out his locker and backpack and design an organization system that worked for him.

Change our actions:

I started to look for and praise the emerging adult in him. When I saw him do something such as refill the dog’s water bowl, I acknowledged his thoughtfulness (rather than praising completing a chore). When he started to get himself up in the morning using his alarm clock, I made sure he overheard me on the phone telling my sister about how impressed I was at his growing independent skills.

Change our way of demonstrating love:

Danny liked receiving little gifts, so I would make sure I got him something he liked at the grocery store. He loved a certain kind of wavy potato chip, so I would get him his own bag every once in a while, for example.

I also wanted him to give us a way to demonstrate his love, so we discussed how he could contribute to the household. As you can imagine, chores like taking out the trash were not getting done and were also creating a lot of stress between us. He also wanted to cook, so he planned and prepared a meal for the whole family at least once a week. He got so into it, he would write up menus and not allow anyone into the kitchen while he cooked. Cooking for us gave him confidence, acknowledgement and a sense of real contribution.

Danny has ADHD that he now accepts and understands. He knows he actually needs to fidget, that he learns better with music on and that he has a quick mind. He has also accepted that he is bright, capable and a fast hands-on learner.

As I have learned to love and accept my son, he has learned to love and accept himself. What could be better than that?

Dr. Michael Rubino is a psychotherapist with over 20 years experience treating children and teenagers.  Many of these children and teens have ADHD and ODD.  For more information about Dr. Rubino’s work and private practice visit his website at www.RubinoCounseling.com or follow him on Twitter @RubinoTherapy.

The Truth about Teenage Boys and Anxiety

In our society people do not discuss mental health and it is something people feel embarrassed about.  They also feel shame if they have mental health issues or if they go to a psychotherapist. However, school and college are starting very soon and school can trigger emotional issues for many adolescents.

While we have this negative stigma about mental health, teenagers worry about it a great deal.  Especially since 1 out of 5 teenagers deal with mental health issue.  As a psychotherapist who treats teenagers, I see a large number of teens for panic attacks especially boys.  I believe teenage boys are more prone to anxiety attacks because of the stereotype that boys don’t cry and they see emotions as weak.  However, in our society men do cry and have emotional problems.  Emotions are not a sign of weakness for men and boys. The documentary, “The Mask You Live In,” address this issue that men and boys face.  I recently read an article by the basketball player, Kevin Love, which addresses this issue and explains how it impacts men and boys.  I have included what he wrote so you can understand what men and boys face in our society.

On November 5th, right after halftime against the Hawks, I had a panic attack.

It came out of nowhere. I’d never had one before. I didn’t even know if they were real. But it was real — as real as a broken hand or a sprained ankle. Since that day, almost everything about the way I think about my mental health has changed.

“I DID ONE SEEMINGLY LITTLE THING THAT TURNED OUT TO BE A BIG THING.”

Kevin Love discusses his decision to seek help after suffering from a panic attack. (0:54)

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I’ve never been comfortable sharing much about myself. I turned 29 in September and for pretty much 29 years of my life I have been protective about anything and everything in my inner life. I was comfortable talking about basketball — but that came natural. It was much harder to share personal stuff, and looking back now I know I could have really benefited from having someone to talk to over the years. But I didn’t share — not to my family, not to my best friends, not in public. Today, I’ve realized I need to change that. I want to share some of my thoughts about my panic attack and what’s happened since. If you’re suffering silently like I was, then you know how it can feel like nobody really gets it. Partly, I want to do it for me, but mostly, I want to do it because people don’t talk about mental health enough. And men and boys are probably the farthest behind.

I know it from experience. Growing up, you figure out really quickly how a boy is supposed to act. You learn what it takes to “be a man.” It’s like a playbook: Be strong. Don’t talk about your feelings. Get through it on your own. So for 29 years of my life, I followed that playbook. And look, I’m probably not telling you anything new here. These values about men and toughness are so ordinary that they’re everywhere … and invisible at the same time, surrounding us like air or water. They’re a lot like depression or anxiety in that way.

So for 29 years, I thought about mental health as someone else’s problem. Sure, I knew on some level that some people benefited from asking for help or opening up. I just never thought it was for me. To me, it was form of weakness that could derail my success in sports or make me seem weird or different.

PHOTO BY CHRISTIAN PETERSEN/GETTY IMAGES

Then came the panic attack.

It happened during a game.

It was November 5th, two months and three days after I turned 29. We were at home against the Hawks — 10th game of the season. A perfect storm of things was about to collide. I was stressed about issues I’d been having with my family. I wasn’t sleeping well. On the court, I think the expectations for the season, combined with our 4–5 start, were weighing on me.

I knew something was wrong almost right after tip-off.

I was winded within the first few possessions. That was strange. And my game was just off. I played 15 minutes of the first half and made one basket and two free throws.

After halftime, it all hit the fan. Coach Lue called a timeout in the third quarter. When I got to the bench, I felt my heart racing faster than usual. Then I was having trouble catching my breath. It’s hard to describe, but everything was spinning, like my brain was trying to climb out of my head. The air felt thick and heavy. My mouth was like chalk. I remember our assistant coach yelling something about a defensive set. I nodded, but I didn’t hear much of what he said. By that point, I was freaking out. When I got up to walk out of the huddle, I knew I couldn’t reenter the game — like, literally couldn’t do it physically.

Coach Lue came up to me. I think he could sense something was wrong. I blurted something like, “I’ll be right back,” and I ran back to the locker room. I was running from room to room, like I was looking for something I couldn’t find. Really I was just hoping my heart would stop racing. It was like my body was trying to say to me, You’re about to die. I ended up on the floor in the training room, lying on my back, trying to get enough air to breathe.

The next part was a blur. Someone from the Cavs accompanied me to the Cleveland Clinic. They ran a bunch of tests. Everything seemed to check out, which was a relief. But I remember leaving the hospital thinking, Wait … then what the hell just happened?

PHOTO BY JED JACOBSOHN/THE PLAYERS' TRIBUNE

I was back for our next game against the Bucks two days later. We won, and I had 32. I remember how relieved I was to be back on the court and feeling more like myself. But I distinctly remember being more relieved than anything that nobody had found out why I had left the game against Atlanta. A few people in the organization knew, sure, but most people didn’t and no one had written about it.

A few more days passed. Things were going great on the court, but something was weighing on me.

Why was I so concerned with people finding out?

It was a wake-up call, that moment. I’d thought the hardest part was over after I had the panic attack. It was the opposite. Now I was left wondering why it happened — and why I didn’t want to talk about it.

Call it a stigma or call it fear or insecurity — you can call it a number of things — but what I was worried about wasn’t just my own inner struggles but how difficult it was to talk about them. I didn’t want people to perceive me as somehow less reliable as a teammate, and it all went back to the playbook I’d learned growing up.

This was new territory for me, and it was pretty confusing. But I was certain about one thing: I couldn’t bury what had happened and try to move forward. As much as part of me wanted to, I couldn’t allow myself to dismiss the panic attack and everything underneath it. I didn’t want to have to deal with everything sometime in the future, when it might be worse. I knew that much.

So I did one seemingly little thing that turned out to be a big thing. The Cavs helped me find a therapist, and I set up an appointment. I gotta stop right here and just say: I’m the last person who’d have thought I’d be seeing a therapist. I remember when I was two or three years into the league, a friend asked me why NBA players didn’t see therapists. I scoffed at the idea. No way any of us is gonna talk to someone. I was 20 or 21 years old, and I’d grown up around basketball. And on basketball teams? Nobody talked about what they were struggling with on the inside. I remember thinking, What are my problems? I’m healthy. I play basketball for a living. What do I have to worry about? I’d never heard of any pro athlete talking about mental health, and I didn’t want to be the only one. I didn’t want to look weak. Honestly, I just didn’t think I needed it. It’s like the playbook said — figure it out on your own, like everyone else around me always had.

PHOTO BY JEFF HAYNES/NBAE/GETTY IMAGES

But it’s kind of strange when you think about it. In the NBA, you have trained professionals to fine-tune your life in so many areas. Coaches, trainers and nutritionists have had a presence in my life for years. But none of those people could help me in the way I needed when I was lying on the floor struggling to breathe.

Still, I went to my first appointment with the therapist with some skepticism. I had one foot out the door. But he surprised me. For one thing, basketball wasn’t the main focus. He had a sense that the NBA wasn’t the main reason I was there that day, which turned out to be refreshing. Instead, we talked about a range of non-basketball things, and I realized how many issues come from places that you may not realize until you really look into them. I think it’s easy to assume we know ourselves, but once you peel back the layers it’s amazing how much there is to still discover.

A message from Kevin Love's Grandma

“HAPPY BIRTHDAY, KEVIN.”

Kevin’s grandmother records a greeting for his 25th birthday in 2013. (0:33)

Since then, we’ve met up whenever I was back in town, probably a few times each month. One of the biggest breakthroughs happened one day in December when we got to talking about my Grandma Carol. She was the pillar of our family. Growing up, she lived with us, and in a lot of ways she was like another parent to me and my brother and sister. She was the woman who had a shrine to each of her grandkids in her room — pictures, awards, letters pinned up on the wall. And she was someone with simple values that I admired. It was funny, I once gave her a random pair of new Nikes, and she was so blown away that she called me to say thank you a handful of times over the year that followed.

When I made the NBA, she was getting older, and I didn’t see her as often as I used to. During my sixth year with the T-Wolves, Grandma Carol made plans to visit me in Minnesota for Thanksgiving. Then right before the trip, she was hospitalized for an issue with her arteries. She had to cancel her trip. Then her condition got worse quickly, and she fell into a coma. A few days later, she was gone.

I was devastated for a long time. But I hadn’t really ever talked about it. Telling a stranger about my grandma made me see how much pain it was still causing me. Digging into it, I realized that what hurt most was not being able to say a proper goodbye. I’d never had a chance to really grieve, and I felt terrible that I hadn’t been in better touch with her in her last years. But I had buried those emotions since her passing and said to myself, I have to focus on basketball. I’ll deal with it later. Be a man.

The reason I’m telling you about my grandma isn’t really even about her. I still miss her a ton and I’m probably still grieving in a way, but I wanted to share that story because of how eye-opening it was to talk about it. In the short time I’ve been meeting with the therapist, I’ve seen the power of saying things out loud in a setting like that. And it’s not some magical process. It’s terrifying and awkward and hard, at least in my experience so far. I know you don’t just get rid of problems by talking about them, but I’ve learned that over time maybe you can better understand them and make them more manageable. Look, I’m not saying, Everyone go see a therapist. The biggest lesson for me since November wasn’t about a therapist — it was about confronting the fact that I needed help.

PHOTO BY BRANDON DILL/AP IMAGES

One of the reasons I wanted to write this comes from reading DeMar’s comments last week about depression. I’ve played against DeMar for years, but I never could’ve guessed that he was struggling with anything. It really makes you think about how we are all walking around with experiences and struggles — all kinds of things — and we sometimes think we’re the only ones going through them. The reality is that we probably have a lot in common with what our friends and colleagues and neighbors are dealing with. So I’m not saying everyone should share all their deepest secrets — not everything should be public and it’s every person’s choice. But creating a better environment for talking about mental health … that’s where we need to get to.

Because just by sharing what he shared, DeMar probably helped some people — and maybe a lot more people than we know — feel like they aren’t crazy or weird to be struggling with depression. His comments helped take some power away from that stigma, and I think that’s where the hope is.

I want to make it clear that I don’t have things figured out about all of this. I’m just starting to do the hard work of getting to know myself. For 29 years, I avoided that. Now, I’m trying to be truthful with myself. I’m trying to be good to the people in my life. I’m trying to face the uncomfortable stuff in life while also enjoying, and being grateful for, the good stuff. I’m trying to embrace it all, the good, bad and ugly.

I want to end with something I’m trying to remind myself about these days: Everyone is going through something that we can’t see.

I want to write that again: Everyone is going through something that we can’t see.

The thing is, because we can’t see it, we don’t know who’s going through what and we don’t know when and we don’t always know why. Mental health is an invisible thing, but it touches all of us at some point or another. It’s part of life. Like DeMar said, “You never know what that person is going through.”

Mental health isn’t just an athlete thing. What you do for a living doesn’t have to define who you are. This is an everyone thing. No matter what our circumstances, we’re all carrying around things that hurt — and they can hurt us if we keep them buried inside. Not talking about our inner lives robs us of really getting to know ourselves and robs us of the chance to reach out to others in need. So if you’re reading this and you’re having a hard time, no matter how big or small it seems to you, I want to remind you that you’re not weird or different for sharing what you’re going through.

Just the opposite. It could be the most important thing you do. It was for me.

Dr. Michael Rubino is a psychotherapist with over 20 years of experience treating teenagers and children.  For more information about Dr. Rubino’s work or private practice visit his website www.RubinoCounseling.com or follow him on Twitter @RubinoTherapy.

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New Teen Drugs

Over the next few weeks, students will be starting high school and middle school.  Many parents are concerned about the challenges their children will experience in these environments.  A common one is peer pressure and drugs.  As a psychotherapist who treats teenagers, I hear about what is going on with teenagers and what they are doing.  I have been hearing from many teens about new designer drugs they are taking.  Many people assume teenagers are primarily using marijuana. However, teenagers are looking for new drugs and ways to modify how they use marijuana.  These new drugs can be very dangerous, even deadly.  However, many teenagers are not aware of the dangers and risks they are taking.

As summer ends many teens will want to get in one more party.  As school resumes for many teenagers this means partying with old and new friends.  Drugs are often part of these parties.  One major problem facing teens is the fact that many Emergency Room physicians cannot keep up with all the new drugs teenagers are using.  Therefore, if a teenager ends up in the Emergency Room due to overdosing or having a bad reaction to one of these new drugs, a teenager may die before an Emergency Room physician determines what the teenager took and how to treat it.  The show The Good Doctor recently had an episode which addressed this issue.  The teen had used, Molly, not a new drug but because there were so many options, the teenager almost died before they could determine how to treat him.

Recently I read an article by Angela Chen.  The article discusses these new dangerous drugs and how deadly these drugs can be.  I have included her article below so parents can be aware of the dangers facing their teenagers.  Hopefully, parents will also take this opportunity to discuss this issue with their teenagers.

On a July day a little over a year ago, over 30 people collapsed on a street in Brooklyn. They lay on the ground, vomiting down their shirts, twitching and blank-faced. Some, half-naked, made jerking movements with their arms, eyes rolled back. Others groaned and clutched onto fire hydrants to try to stay upright. Witnesses said the scene was like The Walking Dead. Headlines claimed that people had turned into “zombies,” while police said that the 33 affected were lucky to be alive.

All had smoked an “herbal incense” product called AK-47 24 Karat Gold. Eighteen people were sent to the hospital by ambulance. The situation had all the signs of a drug overdose, and so doctors ordered the usual tests: blood count, urine analysis, heart rate monitoring.

The first patient tested was a 28-year-old man who was slow to respond, but otherwise showed few clear signs of trauma. Heart sounds: normal. Blood count: normal. His lungs were clear and there were no major neurological problems, no excessive sweating or skin lesions. He tested negative for opiates, cocaine, amphetamines. Nothing came up.

The case went to the Department of Homeland Security and the Drug Enforcement Agency. They knew who to call to get a second opinion. They packed blood and urine samples on dry ice and shipped them to a small lab 3,000 miles away in San Francisco, run by toxicologist Roy Gerona. If anyone in the country could figure out what was in 24 Karat Gold, it would be him.

Forty years ago, drugs had easy names: cocaine, meth, heroin. Today, the names can read like an ingredients list for a chemistry class: 5F-AMB, PX-2, MDMB-CHMINACA. Today’s designer drugs are made by synthesizing chemicals and hoping they give you a high that’s strong enough to be worth it, but not strong enough to send you to the hospital.

Designer drugs are volatile. If you tweak just one molecule, you can get an entirely differently substance, one you hadn’t bargained for. They’re also easy to get. There’s no shortage of “research chemicals” vendors on the dark web are willing to sell. And they’re growing more popular. These so-called “novel psychoactive substances” entered the mainstream in 2009. That year, according to the United Nations Office on Drug and Crime, there were about 100 of these substances reported; six years later, there were nearly 500. Because designer drugs don’t show up on traditional drug tests, they’re hard to track and identify. It’s a public health problem that requires a special set of skills to handle.

One of the most prominent categories of designer drugs are those intended to mimic marijuana, called synthetic cannabinoids. Marijuana, or cannabis, is widely considered one of the safest drugs, but synthetic cannabinoids are some of the most dangerous synthetic drugs. The Global Drug Survey (GDS) found that last year, for the fourth year running, the risk of seeking emergency medical treatment was higher after using synthetic weed than for any other drug.

When you smoke a regular joint, a chemical called tetrahydrocannabinol (THC) travels through your blood. It binds with receptors called CB1 and CB2. Because of the structure, there’s “kind of a limit on how stoned you can get,” says Adam Winstock, a London-based psychiatrist who administers the GDS. If you’re smoking a popular cannabinoid like K2 Spice, a chemical travels through your blood, but this time, it’s not THC. It’s something else that also binds with CB1 and CB2 — but unlike with regular weed, we don’t know exactly how these chemicals bind, especially when they’re illicit drugs from the black market. This mystery makes synthetic marijuana likely to lead to “much more extreme responses,” like seizures and psychosis, according to Winstock.

Synthetic cannabinoids originated in a quest to create a better pain medication. A Clemson University chemist named John W. Huffman synthesized hundreds of compounds in an attempt to find a better painkiller, but often created incredibly psychoactive substances with no medicinal properties at all. When he published the results of these compounds — called JWH compounds, after his initials — he made the information available to be copied.

There are more than 300 JWH compounds alone, and around 2004, labs in China began studying old research papers, synthesizing the compounds and distributing them as “herbal incense” products. K2 Spice itself — often partly based off the JWH-018 compound — started in China, became popular in Germany around 2008, and entered the US around 2009.

Labs can also turn to the expired patents — patents that are rich fodder, even if (or perhaps because) there was a good reason said drugs never made it to market. It’s nearly impossible to figure out how to shut down the overseas labs producing these drugs. As soon as you ban one substance, the labs move on to another.

Gerona, a toxicologist with gray hair styled in an undercut, was the one who received the biological samples from the DEA. From a small lab in the Medical Sciences Building at the University of California, San Francisco, Gerona says he and his team are playing a “cat and mouse game” with illicit international drug manufacturers. When an overdose happens, Gerona’s team tries to identify the drug in question — often synthetic substances no one has seen before. But the lab goes one further: Gerona’s lab attempts to identify and classify these substances before the mass overdoses even happen.

Inside, the lab is meticulously neat: rows of spotless tables are covered in bottles with orange rubber caps, all labeled with orange duct tape, and small gray centrifuges. A window overlooking a courtyard has molecular structures scribbled over it in pink and green marker. Near the door sits an enormous freezer, filled with thousands of brightly colored, frost-covered boxes of drug samples kept at -112 degrees Fahrenheit.

Gerona launched his toxicology lab in 2010, in partnership with the San Francisco Poison Control Center. The date wasn’t a coincidence; he says that 2010 was the year that a designer drug called “bath salts” began flooding the market. “Bath salts” is a blanket term for a group of designer drugs made from stimulants; they create a euphoric high like MDMA, sometimes with hallucinations thrown in. The drugs usually come in powdered and capsule form, and can cause freak-outs that were well-documented on YouTube at the time. The most famous of these was a viral story of a 31-year-old Miami resident attacking and then eating a homeless man. (Scientists dispute the drugs’ role.)

For users and the DEA, the spike in bath salts use was a nightmare. For Gerona, the increased interest in designer drugs led to more work and more samples from around the country. Eventually, the lab caught the notice of both Michael Schwartz, a toxicologist at the Centers for Disease Control and Prevention, and DEA pharmacologist Jordan Trecki. A collaboration between Gerona’s lab and the DEA was formed. (Neither the DEA nor the CDC responded to repeated requests for comment.)

The first step in doing an analysis at Gerona’s lab is getting the sample — urine, blood or, rarely, a tiny bit of drug itself — shipped over on dry ice. In traditional drug testing, you check to see if the sample matches any of the known substances: marijuana, heroin, cocaine, and so on. They match, or they don’t. Designer drugs, almost by definition, are made of chemical combinations we haven’t seen before. They almost never match traditional databases, and the chemists often don’t know what they’re looking for. So Gerona’s lab gathers as much information about the substance as possible.

A tiny vial of the biological sample — usually plasma, the colorless part of blood — goes into a bulky, printer-like machine. That machine is called a liquid chromatography mass spectrometer, and very crudely put, it separates out all the different parts of the plasma by mass. (Think of it like an extremely sensitive centrifuge.) That process makes it easier to identify chemicals, and the mass spectrometer then spits out the different measurements in a computer chart with peaks and valleys called a chromatogram.

Then, says Axel Adams, a graduate student in Gerona’s lab, you turn to the so-called “prophetic library.”

“ RESEARCHES LOOK FOR POSTS ABOUT DRUGS ON SUBREDDITS LIKE R/RESEARCHCHEMICALS

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Gerona’s “prophetic library,” about three years in the making, is a detailed catalog of already synthesized variants that his team believes is going to be the next big street drug. The library was made possible with the help of Samuel Banister, a synthetic chemist at Stanford University. Banister synthesizes variants of popular street drugs and takes down their chemical information to create “reference standards.” Synthesizing can take anywhere from a few days to a couple of weeks; the lab now has almost 150 variants on file. It’s a side job for Banister, but at one point, he says, “I was pumping out five to 10 a week.” The final products look like white crystalline solids and are kept in drawers in the lab, ready for when a case like AK-47 24 Karat Gold comes along.

In addition, lab members spend hours each week on drug forums, researching trends. It’s more of an art than a science. Researches look for posts about drugs on subreddits like r/researchchemicals. They reference surveys like the Global Drug Survey and survey “trip reports” from experiential documentation sites like Erowid and PsychonautWiki.

They look for terms like synthetic pot, K2, Spice, and sometimes, scientific terms like “cannabinoids,” or a specific popular class of cannabinoids, like “FUBINACA” or “JWH compounds.” Often, the posts themselves will include the name of the chemical. Gerona has ordered drugs off the dark web. In one case, the invoice billed him for “cosmetics,” and the package included lipstick, fake eyelashes, and tabs labeled “powder.” The “powder,” unsurprisingly, turned out to be drugs. But most of the time, the drugs in the powder were not the drug that was ordered.

“ THE INVOICE BILLED HIM FOR “COSMETICS,” AND THE PACKAGE INCLUDED LIPSTICK, FAKE EYELASHES, AND TABS LABELED “POWDER”

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If there is a match because the compound is already in the library, finding the right variant is “only going to take 15 minutes,” says Gerona. “Otherwise, it could take a week, or it could not be solved.”

Adams checked the results of a blood sample tied to AK-47 24 Karat Gold against the prophetic library. The computer pulled up a chart that indicated a line — jagged, up and down — that shows the mass of the components of AK-47 24 Karat Gold, versus the same information for AMB-FUBINACA.

Drugs don’t pass through the body untouched. Once they’re ingested, the body processes the compounds. So by the time they’re in the blood or urine, it’s not exactly the same compound as the drug that was ingested. It’s hard enough to find a reference standard for the original compound; it’s even more difficult to find a reference standard for the possible variants. In the case of AMB-FUBINACA, the chemical in the biological sample from Brooklyn wasn’t the parent compound. It was a derivative. Luckily, Banister had already synthesized that variant, too.

The peaks and valleys of the two lines of AK-47 24 Karat Gold and AMB-FUBINACA matched up precisely. It took the team only seven days to identify the substance in the Brooklyn case — and most of that time was spent waiting for the sample to get there.

Gerona’s lab has worked on cases across the country, from New York City to Sacramento to Colorado. The number of cases varies. Sometimes, they’ll get 15 to 25 samples a month. One Mississippi case involving synthetic cannabinoids resulted in over 400 samples. The average turnaround on results is about six months, says Adams. That’s not good enough for Gerona.

And it’s not likely that the problem will go away. Marijuana legalization advocates claim that people will stop with the synthetic stuff once the real thing is okay. But that’s not true in the experience of Andrew Monte, a clinical toxicologist at the University of Colorado School of Medicine who collaborates with Gerona’s lab. Recreational marijuana is legal in Colorado, but he sees patients who are on these synthetic compounds anyway. Monte’s team has surveyed people who come into the ER and even set up at music festivals to ask attendees questions. Synthetic drug users are “taking it for a different reason, to get a different high,” Monte says. “They’re really looking for something different than what pot gives, the same way you might choose cocaine over pot or meth over pot.”

“ ONE MISSISSIPPI CASE INVOLVING SYNTHETIC CANNABINOIDS RESULTED IN OVER 400 SAMPLES

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To help address this problem, in 2016 Gerona started a new research consortium called P SCAN, or the Psychoactive Surveillance Consortium and Analysis Network. (Yes, the double entendre is intended.) They’re working with about 10 poison control centers in places like Kansas and Colorado. They’ve had more than 100 cases referred to them and are writing up case reports and manuscripts. (The 24 Karat Gold case was published by the New England Journal of Medicine.)

P SCAN will continue to do the surveillance work Gerona has been doing for years, but also create a database of clinical data connected to the specific synthetic drugs they track and discover. Think of it like a medical version of Erowid. This way, the next time there’s an outbreak like the one in Brooklyn, investigators and researchers can look at specific physical indicators (heart rate, respiratory information, neurological information, and more) and say, “Ah, this matches the symptoms of AMB-FUBINACA” — all without shipping samples across the country.

But even with P SCAN and the prophetic library, the task is huge. “The identity of a lab needs to constantly expand and rework in order for it to stay relevant,” says Gerona.

Gerona is a biochemist by training. Before launching his lab, he didn’t know anything about Spice, or AK-47 Gold, or the dark net. But now, Gerona says, “I have no other choice but to really learn about it, so that I am relevant and retain my relevance in the field.” He’s hoping to work with people in technology to automate this “market research” to glean new insights and make the prediction process even faster. “It would be so great if we could predict the drugs coming in with more accuracy, instead of after people are hurt,” he says.

Weeding out designer drugs is a Sisyphean task, Gerona admits. It may be impossible to shut down the overseas labs, but he wants to have even better methods for predicting what’s going to get big and then, instantly identifying the substances. He compares the endless drug variations to nature: the cold virus is still around because it changes all the time. HIV has never been cured because it continues mutating. “In a sense, they’re reinventing themselves all the time, so reinvention is key to persistence. As long as you’re reinventing yourself, you can persist.

Dr. Michael Rubino is a psychotherapist with over 20 years experience treating teenagers.  He treats teenagers with drug issues and has seen many end up in the Emergency Room because teenagers think they are the experts.  For more information about Dr. Rubino’s work or his private practice visit his website www.RubinoCounseling.com or his Facebook page www.Facebook.com/Drrubino3.