E-DRUG: Non-medical use of ARVs
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[Follow-up to: BBC: Getting high on HIV drugs in S Africa (3)]
Dear e-druggers,
Drugs that produce hallucinatory effects typically are related
structurally to the neurotransmitter serotonin. Other neurotransmitters
may be involved for some drugs, including acetylcholine (scopolamine),
norepinephrine (mescaline), and glutamate/N-methyl-D-aspartate
(phencyclidine, ketamine). Many medications have a record of producing
hallucinations (labeled a side effect or adverse reaction) in small
numbers of patients, often seen during clinical trials on the medication
or later post-marketing surveillance, or through unusual patterns of use
(high doses, certain routes of administration). This can be noted in the
drug's monograph, and hallucinations are listed as an adverse reaction
from efavirenz.
While a pharmacy extern in Minneapolis in 1977, there was a brief
"outbreak" of non-medical use of penicillin at the clinic where I
worked. Users were taking very high (toxic) doses, sometimes via
injection, and reporting hallucinatory effects, which are listed as an
adverse reaction in the drug's monograph. Many other approved
medications have been used non-medically over the years to produce these
types of effects. While SAR can be a good preliminary indicator of
potential effects, it is not the only indicator of potential non-medical
use of a medication to obtain these effects; consider the following:
1. Users report hallucinatory effects from a drug, but do they mean
true hallucinations or simply visual changes or disturbances? There is a
big difference and most of the time, they mean the latter. In either
case, however, from the user's perspective they might not care; they
just want to get "high" (a word with many definitions and meanings).
2. People tend to use those drugs that produce psychoactive effects
in most users most of the time it is used, not those drugs that may
produce these effects in limited number of users or only if greatly
misused (high or toxic doses, unusual routes of administration,
polypharmacy).
3. Non-medical drug users prefer those drugs that are accessible
(inexpensive, available), produce few side effects (that are minimally
unpleasant), and legal (or with minimal sanctions if caught with them).
If not, then users look for less desirable alternatives to achieve
effects.
4. Users have reported hallucinatory effects from drugs that have
no SAR suggesting such effects or a record of these effects from past
users (clinical trial data, user accounts in "underground" literature).
In these cases, social and cultural factors may generate expectations
about a drug's effects which then occur after ingestion of the drug (in
which the so-called "non-pharmacological" factors are more important
than pharmacological activity in predicting or producing drug effects).
It is likely that some users of efavirenz experience hallucinatory
effects from this medication; a greater likelihood if taken in high
doses or through certain routes of administration. Knowledge of these
effects will spread through local social networks of users, and many may
try it. Non-medical use will increase if the drug is accessible, if few
or no alternatives are available, if other negative effects are not
experienced, and if sanctions against non-medical use are minimal. Some
will use even in the presence of serious adverse effects, severe legal
or social sanctions against use, or perhaps for reasons of novelty or
because peers are using the drug.
It still is important to note these early cases of non-medical use for
specific effects. Strategies can be implemented hopefully to prevent or
limit escalation of non-medical use in a local population. Early reports
such as these are useful in counseling patients and non-medical users
about the inherent risks in non-medical use. But at the same time, we
must realize that some users will interpret and apply this information
in a type of drug taking that Sesay termed "chemotherapeutic suicide".
Ref:
Julien, RM. A Primer of Drug Action: A comprehensive guide to the
actions, uses, and side effects of psychoactive drugs. 11th ed. WH
Freeman & Co, 2007.
Sincerely,
Mike
Michael Montagne, PhD
Professor of Social Pharmacy
Senior Associate Dean of Pharmaceutical Education
Massachusetts College of Pharmacy & Health Sciences
179 Longwood Ave
Boston MA 02115
phone: 617-732-2995
email: michael.montagne@mcphs.edu