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Recreational Drugs, HIV, and Antiretroviral Therapy

Modified by: Patrick Clay, PharmD UNT System College of Pharmacy Patrick.Clay@unthsc.edu O: (817) 735-2798 Originally designed and developed by: Frank Romanelli, Pharm.D ., MPH, BCPS Professor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education, University of Kentucky.

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Recreational Drugs, HIV, and Antiretroviral Therapy

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  1. Modified by:Patrick Clay, PharmDUNT System College of PharmacyPatrick.Clay@unthsc.eduO: (817) 735-2798Originally designed and developed by:Frank Romanelli, Pharm.D., MPH, BCPSProfessor of Pharmacy, Medicine, & Health Sciences Associate Dean for Education, University of Kentucky Recreational Drugs, HIV, and Antiretroviral Therapy

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

  3. ICE CHRISTINA Special K m&m Georgia Home Boy Poppers KitKat Roach TINA X Easy Lay G Roofies CHRYSTAL

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

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

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

  7. Club Drugs • Methylenedioxymethamphetamine (MDMA) “Ecstasy” • Gammahydroxybutyric Acid (GHB) “G” • Ketamine “Special K” • Amyl and Butyl Nitrites “Poppers” • 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 • Within the US, National Drug Intelligence Center now equates MDMA use to that of heroin and cocaine. • MDMA estimated to be one of the fastest growing drug of abuse in the US. • 2000: 1.4 million HS seniors used MDMA. • 2005: 2.5% of HS seniors reported ‘ever-use.’

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

  11. What does “Hug Drug” look like? Audience Participation time! White tablet Pink capsule Never scored

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

  13. Street Sales • Sold in tablet form • Typical tablet contains 50-150mg of active ingredient • Cost: $20-40.00 per tablet

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

  15. Clinical Effects • Increased energy • Talkative, open-minded • Intimacy • Distorted senses • Decreased fear, aggression, defensiveness • Hallucinations • Teeth grinding

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

  17. Availability • Controlled substance C-I • Internet recipes available • Gammabutyrolactone (GBL) • 1,4-butanediol (1,4-BD)

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

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

  20. Street Sales • Oral dosage form • Typical dose “one capful” • Often admixed into water bottles • $5.00-$10.00/dose

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

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

  23. What rec drug was found in the characters portrayed in the movie, Armageddon X Kit Kat Poppers Ice

  24. Ketamine Derivative of phencyclidine (PCP), introduced in the 1960s and used as a dissociative anesthetic • Special K, “K”, Kit-Kat, Super K • Jet, Super Acid

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

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

  27. Street Sales • Injection product (IV or IM) • Ingestion • Smoking • Snorting • $80.00/gram

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

  29. Clinical Effects • Analgesic effects at lower doses, with amnestic effects at increasing doses • Dramatic feelings of dissociation “floating over one’s body” into “K-land” or “K-holes” • Visual hallucinations and lack of coordination are common • Many abusers report effects dependent upon the setting within which the drug is abused

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

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

  32. Street Sales • Inhalation • Sold in small amber glass ampoules • Typical unit dose for sale contains 10-30 cc of drug • Cost: $10-20 per ampoule

  33. Clinical Effects • Feelings of a “rush”, warmth, dizziness • Reduce anal sphincter tone • Increased sexual intensity • Methemeglobinemia • Early association with HIV and KS • Interaction with PDEs**

  34. Methamphetamine Crystal, Tina, glass Speed, Meth, Crank

  35. Historical AspectsWorldwide • Synthesized in late 1800s and studied in the 1930s • First epidemic occurred during and after WWII (1945-1957) • By 1948 - 5% of Japanese aged 16-25 were users, restrictions enacted in 1951 • Gradual west to east movement of MA use from Japan, to Hawaii, to the US west coast (motorcycle gangs)

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

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

  38. Epidemiology • In US from 1992-2002, MA-related admissions to treatment programs rose from 10 to 52/100K persons • Extent of MA abuse seems to be concentrated in West, Midwest, and South • Subpopulations: MSM, homeless, rural areas

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

  40. Methamphetamine Labs

  41. Cost • Compared to other illicit drugs: inexpensive • $25 per 1/4 gram • $100 per gram • $1,700 per ounce

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

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