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Originally designed and developed by: Frank Romanelli, Pharm.D., MPH, BCPS Professor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education,

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Presentation on theme: "Originally designed and developed by: Frank Romanelli, Pharm.D., MPH, BCPS Professor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education,"— Presentation transcript:

1 Originally designed and developed by: Frank Romanelli, Pharm.D., MPH, BCPS Professor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education, University of Kentucky Modified by: Patrick Clay, PharmD UNT System College of Pharmacy O: (817) Originally designed and developed by: Frank Romanelli, Pharm.D., MPH, BCPS Professor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education, University of Kentucky Recreational Drugs, HIV, and Antiretroviral Therapy

2 Objectives l Define the term club drugs. l List potential clinical and toxic effects of club and recreational drugs. l Describe potential effects of recreational drug use upon ARV therapy. l Discuss HIV specific adverse consequences of recreational drug use.

3 m&m Special K ICE

4 CLUB DRUGS Recreational Drugs *SOCIAL LUBRICANTS* Substances used in a recreational fashion to enhance social experiences.

5 Club Drugs l Not all recreational drugs are considered Club Drugs l Produce dis-inhibition l Common substances of abuse at bars, circuit parties, raves

6 RaveCircuit Party l All night parties involving loud music, laser light shows, and marathon dancing. l Most commonly held in large open areas such as old warehouses. l Most commonly three day weekend events centered in large urban areas. l Attendees pay one lump sum to attend multiple events throughout the weekend culminating in one final large party.

7 Club Drugs l Methylenedioxymethamphetamine (MDMA) Ecstasy l Gammahydroxybutyric Acid (GHB) G l Ketamine Special K l Amyl and Butyl Nitrites Poppers l Methamphetamine Crystal Tina

8 Methylenedioxymethamphetamine Amphetamine derivative which leads to exaggerated levels of neurotransmitters throughout the CNS. Ecstasy, E, XTC M and M Hug Drug

9 Epidemiology l Within the US, National Drug Intelligence Center now equates MDMA use to that of heroin and cocaine. l MDMA estimated to be one of the fastest growing drug of abuse in the US. l 2000: 1.4 million HS seniors used MDMA. l 2005: 2.5% of HS seniors reported ever-use.

10 Availability l Amsterdam – Ecstasy Capitol of the World l Commonly manufactured in clandestine laboratories l High level of impurities and contaminants (DM, ASA, Pseudoephedrine)

11 What does Hug Drug look like? Audience Participation time! A. White tablet B. Pink capsule C. Never scored


13 History of Abuse l Created in 1914 for appetite control l Used in 1970s as a means of enhancing behavior therapy l Entered club scene in 1980s l Classified as a C-I l 2001, FDA approval of trial involving post-traumatic stress disorder

14 Street Sales l Sold in tablet form l Typical tablet contains mg of active ingredient l Cost: $ per tablet

15 Pharmacology l Structurally related to the stimulant methamphetamine and hallucinogen mescaline l Increases levels of all NTs within CNS synapses l Inhibition of MAO

16 Clinical Effects l Increased energy l Talkative, open-minded l Intimacy l Distorted senses l Decreased fear, aggression, defensiveness l Hallucinations l Teeth grinding





21 Gamma-hydroxybutyrate Naturally occurring fatty acid derivative of CNS neurotransmitter GABA l Liquid E l Gib, GBH, Grievous Bodily Harm, Georgia Home Boy, G l Soap, Scoop, Salty Water l Easy Lay

22 Availability l Controlled substance C-I l Internet recipes available l Gammabutyrolactone (GBL) l 1,4-butanediol (1,4-BD)

23 History of Abuse l Early 1990s - Dietary supplement purported to increase muscle mass, increase libido, metabolize fat l Mid-1990s - Popularity increased, euphoric effects recognized l Late 1990s – Established club and date rape drug, FDA ban on OTC sales

24 History of Abuse l 2000 – C-I status in US l Early GBL and 1,4-BD become popular precursor sources of GHB l FDA issues warning letters re: GBL and 1,4-BD l Commonly imported from Europe l Manufactured from internet recipes and clandestine labs

25 Street Sales l Oral dosage form l Typical dose one capful l Often admixed into water bottles l $5.00-$10.00/dose

26 Pharmacology l Normally 1/1000 th the concentrations of GABA within CNS l GHB endogenous CNS chemical l Mediates: sleep cycles, temperature, memory l Gets in your head easily (lipophilic, crosses BBB rapidly) l Impacts levels of growth hormone

27 Clinical Effects l Dose-related CNS depression l Amplification with ethanol or other CNS depressants l Often ingested to counteract euphoric effects of ecstasy

28 What rec drug was found in the characters portrayed in the movie, Armageddon A. X B. Kit Kat C. Poppers D. Ice

29 Ketamine Derivative of phencyclidine (PCP), introduced in the 1960s and used as a dissociative anesthetic l Special K, K, Kit-Kat, Super K l Jet, Super Acid

30 Availability l C-III - Injectable prescription formulation (Ketalar®) l Use has dwindled with advent of safer, more effective anesthetics l Common vet agent l Difficult to manufacture and most often acquired through diversion of the Rx product

31 History of Abuse l Believed to have entered rave scene in mid-1980s l Originally may have been an adulterant of MDMA tablets l As abusers became familiar with the effects of ketamine, its use as a sole agent emerged

32 Street Sales l Injection product (IV or IM) l Ingestion l Smoking l Snorting l $80.00/gram

33 Pharmacology l High bioavailability by both IV or IM route l Oral doses not as well absorbed and undergo first pass metabolism l Interacts with and inhibits NMDA channels (PCP)

34 Clinical Effects l Analgesic effects at lower doses, with amnestic effects at increasing doses l Dramatic feelings of dissociation floating over ones body into K-land or K-holes l Visual hallucinations and lack of coordination are common l Many abusers report effects dependent upon the setting within which the drug is abused

35 Amyl and Butyl Nitrites Volatile nitrite and nitrate derivatives originally intended to produce vasodilatory effects on patients with coronary artery disease. l Poppers

36 Availability l Originally crushable, mesh enclosed pearls l RX product until 1960 when moved to OTC status l 1969 FDA re-instated RX status subsequent to reports of abuse l Banned in 1988


38 Street Sales l Inhalation l Sold in small amber glass ampoules l Typical unit dose for sale contains cc of drug l Cost: $10-20 per ampoule

39 Clinical Effects l Feelings of a rush, warmth, dizziness l Reduce anal sphincter tone l Increased sexual intensity l Methemeglobinemia l Early association with HIV and KS l Interaction with PDEs**

40 Methamphetamine Crystal, Tina, glass Speed, Meth, Crank

41 Historical Aspects Worldwide l Synthesized in late 1800s and studied in the 1930s l First epidemic occurred during and after WWII ( ) l By % of Japanese aged were users, restrictions enacted in 1951 l Gradual west to east movement of MA use from Japan, to Hawaii, to the US west coast (motorcycle gangs)

42 Historical Aspects United States l 1950s: inhalational products available OTC l 1960s: popular use of MA/MA derivatives for obesity l 1970s: restrictions and underground production increases l 1980s: shifts to college students, females, young professionals l 1990s: clandestine labs emerge l 1996: Comprehensive Methamphetamine Control Act l 2000s: enhanced enforcement and regulation; greater international (Mex) trafficking – reductions in Mom & Pop production?

43 Epidemiology l MA now the most widely abused substance in world following cannabis l 35 million estimated MA abusers versus 15 million cocaine abusers l Estimated 5% of US residents have used MA at least once

44 Epidemiology l In US from , MA-related admissions to treatment programs rose from 10 to 52/100K persons l Extent of MA abuse seems to be concentrated in West, Midwest, and South l Subpopulations: MSM, homeless, rural areas

45 Clandestine labs Meth Labs l Utilize readily available and inexpensive chemical products and internet recipes to produce MA l Meth labs carry toxic and explosive risk and considered hazardous waste sites by authorities = costly clean-up l Usually designed to be mobile (trailers, automobile trunks, hotel/motel rooms) l Chemistry beakers, mason jars, coffee filters

46 Methamphetamine Labs



49 Cost l Compared to other illicit drugs: inexpensive l $25 per 1/4 gram l $100 per gram l $1,700 per ounce

50 Clinical Effects - Acute l rush or flash l Flight or fight response l Increased HR, BP, body temperature l Euphoria, alertness, energy l Enhanced sense of well-being/self-esteem l Increased libido and pleasure from sexual activity

51 Clinical Effects - Chronic l Pilot study l Subjects: 65 active MA abusers (by urine screen) l Control: 80 non-abusers l Poor memory (p=0.03) l Manual manipulation of information (p=0.001) Cho A, et al. J Addic Dis 2002; 21:21-34.

52 Adverse Effects - Chronic l Emotional liability (insomnia?) l Paranoid psychosis (insomnia?) l Memory loss (grey matter loss) l Cognitive dysfunction (grey matter loss) l Dermatologic pathology (crank bugs) l Burns l Poor dentition – meth mouth l Withdrawal/Tachyphylaxis

53 meth mouth

54 crank bugs meth sores

55 meth-decay

56 meth decay

57 HIV Recreational Drugs Crossroads

58 Recreational Drug Use (MA) Halkitis PN, et al. J Urban Health 2005; l 450 MSM/bisexual men l 293 (65%) reported MA use in the previous 4 month time-span l AA men less likely to report MA use (p<0.001) l Mean age of MA users: 33±7.9 years

59 Recreational Drug Use Mansergh G, et al. Am J Pub Health l Cross-sectional study of 295 gay and bisexual males in SF Bay Area who attended a circuit party in previous year. l 75% reported use of MDMA l 58% reported use of Ketamine l 25% reported use of GHB l 49% reported having had protected anal sex and 28% unprotected

60 Recreational Drug Use Mansergh G, et al. Klitzman RL, et al. Am J Psychiatry l Pilot study of 169 gay and bisexual men at three NYC clubs. l One-third of all respondents reported use of MDMA at least monthly. l Use of MDMA was statistically significantly correlated with recent and repeated unprotected anal sex.

61 Recreational Drug Use Colfax GN, et al. J Acquir Immune Defic Syndr l Cross-sectional study of gay and bisexual males in SF to examine prevalence of club drug use and high risk sex practices during circuit parties. l 80% reported use of MDMA l 66% reported use of Ketamine l 29% reported use of GHB l 21% of HIV+ and 9% of HIV- persons reported having unprotected anal sex.

62 Recreational Drug Use Mattison AM, et al. Journal of Substance Abuse l Non-random sample of 1169 circuit party attendees in 3 separate venues. l 50% of respondents reported using MDMA within last 30 days l Use of MDMA and ketamine were associated with high risk sexual practices. l Most common reason for attending circuit party was to have uninhibited sex.

63 Recreational Drug Use Ostrow D, Plankey M, Cox C, et al. JAIDS 2009;51: l MACS cohort of HIV-seronegative MSM (n=6,972 males) l Reporting use of both PDEs and other recreational drugs (n=1,667)

64 Results Ostrow D, Plankey M, Cox C, et al. JAIDS 2009;51: HIV + (n=57)HIV – (1610) No drug use33%60% 2 or + URASP21%5% Poppers +/- PDEs33%23% Stimulants33%16% Ethanol (low-mod)60%68% Ethanol (mod- high)25%23% Risk of seroconversion increased from: 2.99 (single drug) [95% CI ] 8.45 (3 drugs (MDMA, poppers, PDEs) [95% CI ]

65 Results Ostrow D, Plankey M, Cox C, et al. JAIDS 2009;51: AgentRisk Stimulant2.99 Poppers3.89 PDE drugs8.45

66 Recreational Drug Use Semple SJ, Strathdee sa, Zians J, et al. BMC Public Health 2010;10:1-6. l 321 participants in a safer-sex intervention surveyed l Survey: drug use and sexual behavior l Cohort split into groups based on preferred sexual venue: private (home); commercial (bathhouse); public (restroom)

67 Recreational Drug Use Semple SJ, Strathdee sa, Zians J, et al. BMC Public Health 2010;10:1-6. l Commercial: > gay, better educated, club drugs l High risk sex greatest in commercial and public groups l Public group: > alcohol use, heavier overall drug use, depression l Mean gm of MA in last 30 d

68 Implications l Rec drugs inc high risk sexual encounters inc rate of STIs. l Potential for fatal interactions in HIV seropositive patients using rec/club drugs. l Potential effects of club drug use on adherence to antiretrovirals? l Potential deleterious disease-related effects withstanding issues surrounding other STIs and ARV adherence

69 -PEARLS- l Respect ritonavir l Start low and have friends nearby l Dont neglect ethanol (ddI, ABC) l Sildenafil: 25 mg q48h Vardenafil: 2.5 mg q72h Tadalafil: 10 mg q 72h l Adherence to ARVs, ancillary meds, appointments, etc. l Dont forget the needles l Patients use recreational drugs … just ask …

70 Why Adopt a Broad View of Adherence? l A broad view of adherence: –recognizes that adherence is not only about taking ones medications –actively engages patients in health care and treatment –values the health impacts of non-medical interventions, including controlled drug use, stable housing, social supports, harm reduction, and good nutrition –improves patients self-efficacy –provides more opportunities for success

71 Adherence: defined l Any action that improves, supports, or promotes the health of a person living with HIV with respect to HIV treatment and care, including physical, mental, and psychosocial well-being.

72 Adherence through HP..helping a patient who uses drugs adhere to a complex medical regimen can support an upward spiral of self-esteem and the adoption of healthier practices.

73 Why focus on adherence in substance abusers? l There is systemic discrimination against substance users –Less access to care –Less access to ART –Slower decline in morbidity and mortality l Providers often lack training in the care of substance users and may have negative attitudes towards them

74 Poor Adherence = … (audience participation time!)

75 HIV resistance:adherence

76 Audience poll: A. An individual should be drug free for one month before they can start antiretroviral therapy. B. An individual should be drug free for three months before they can start antiretroviral therapy. C. An individual should be drug free for six months before they can start therapy.

77 Correct answer: Yes.

78 Adherence & Drug of Choice l Heroin: use may be more regimented –Users may have an easier time w/ adherence l Cocaine/Crack: use may be more sporadic –Intense mood swings may interfere with adherence l Methamphetamine: unclear, but use may be more sporadic and interfere with adherence l Alcohol: may have most negative impact on adherence due to blackouts and memory loss

79 HIV, Psyche, Substance Abuse l Up to 50% to 80% of HIV-infected persons are affected by mental illness. l Triple diagnosis of HIV, substance use, and mental illness is common. l Up to 80% of HIV-infected patients in methadone maintenance require psychiatric consultation for mental illness. l Untreated depression can compromise medication adherence and make HIV infection more disabling.

80 Health Promotion I l Taking all antiretrovirals, on time exactly as prescribed l Taking meds to prevent opportunistic infections l Keeping regular medical appointments l Eating a nutritious diet l Exercising regularly

81 Health Promotion II l Participating in a drug treatment program l Controlling drug use or sobriety l Practicing safer sex and drug injection l Taking a multivitamin l Stopping smoking l Connecting with a support network

82 Take Home Points l Individualize treatment plans to each patients needs. l Recognize the specific challenges of working with HIV infected substance users. l Use knowledge and tools to overcome these challenges and to advocate for patients. l Consider the boundaries for non-medical providers offering HIV adherence and health promotion counseling. l Explore opportunities to link with providers across disciplines to strengthen adherence support.

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