Recreational drug use
Drugs and the law
For the very latest information on the adverse effects and legal status of drugs, you might want to look at the website of the UK drugs information charity Drugscope at http://www.drugscope.org.uk/.
Generally, drugs in the UK are controlled by two laws: the Medicines Act and the Misuse of Drugs Act. The Medicines Act bans the non-medical use of some licensed pharmaceuticals. The Misuse of Drugs Act is concerned with the use of banned drugs, which are placed into different categories. Offences involving Class A drugs carry the stiffest penalties, and offences involving Class C drugs the lightest. A first offence involving possession of drugs is likely to involve a fine or caution. But this would mean that you have a criminal record. Regular offenders, and people who sell or smuggle drugs, can expect to face a prison sentence, and having HIV is unlikely to mean that the courts will deal with you more leniently.
Also see the section on crystal meth below (methamphetamine).
Amphetamines are stimulants normally taken orally, although they can be dissolved in water, snorted or injected. After cannabis, amphetamines are the most widely used illicit drug in the UK, and are classified as a Class B drug in the Misuse of Drugs Act, unless they are prepared for injection, when they are Class A.
Amphetamines cause the heart rate to increase, appetite to diminish, mood to improve and the pupils to dilate. Users often report a 'rush' of confidence lasting three or four hours before they begin to 'come down'. Feelings of anxiety and agitation take over from this point. Repeated use of amphetamines can lead to tolerance of the drug, meaning that you have to take more to achieve a 'high'. Symptoms of anxiety, paranoia and panic can also set in. Prolonged and heavy use can lead to mental disturbances.
Amphetamine use postpones, but does not remove, the need to eat. Regular users often suffer from weight loss and malnutrition. This reduces the body’s ability to fight infection, and this is a major concern for people with HIV, particularly if you have a low CD4 cell count.
There is no clear evidence that HIV-positive users of amphetamine experience faster disease progression, but see the section on crystal meth (methamphetamine).
Anabolic steroids are hormones which are commonly used as drugs to build muscle mass. Body builders and, increasingly, regular gym users often use anabolic steroids in four-week cycles, to improve the effects of their training.
HIV-positive men are sometimes prescribed anabolic steroids or testosterone replacement therapy if they have low natural levels of testosterone or have lost a lot of lean muscle mass.
Steroids can be highly toxic to the liver, and can also cause acne, male pattern baldness, sexual problems and shrinking of the testicles. Women who use anabolic steroids can develop masculine characteristics.
Steroids bought at gyms are often counterfeit or contaminated in some way and can be particularly toxic to the liver and cause nerve damage.
There is controversy about the effect of anabolic steroids on the immune system. Some researchers have argued that they are immunosuppressive, but a study looking at the immune systems of HIV-positive men given prescribed steroid treatment for wasting showed that they did not suppress the immune system. However, it is known that steroid use can increase levels of LDL (bad) cholesterol, so they should be used with extreme caution and under close medical supervision if you have raised blood fats due to your anti-HIV medication.
Needle-sharing by steroid users carries exactly the same risk of HIV and hepatitis B and C transmission as needle-sharing for recreational drug use.
Barbiturates are used medically, to calm people down and as sleeping pills. Barbiturates are a prescription-only drug and are classified as a Class B drug if they are used illegally. Possession is not, however, a criminal offence.
Barbiturates affect the central nervous system, causing a clammy feeling, and depending on the dose, the effects last between three and six hours. They can cause clumsiness, happiness and mental confusion - and unhappiness can also be caused by barbiturates.
Large doses can cause unconsciousness, breathing problems and death. Death from overdose is a very real danger, as there is a fine line between a safe and a dangerous dose. The chances of overdose are increased if barbiturates are taken with alcohol. The risks of barbiturate use are increased if the drug is injected.
The body can rapidly become tolerant of barbiturates, leading to both physical and mental dependence. Withdrawal can involve symptoms of irritability, sleeplessness, sickness, twitching, convulsions and delirium.
Heavy users are more vulnerable to chest complaints and hypothermia.
The legal status of cannabis changed recently in the UK: it was downgraded to a class C drug, but is being reclassified as a class B drug.
Cannabis can be smoked, usually with tobacco, eaten, drunk in a ‘tea' or snorted as a snuff. The drug affects the central nervous system and, as a result, users may experience relief from pain, feel light-headed, relaxed or sleepy. The drug can also stimulate appetite, causing the so-called ‘munchies'. However, cannabis is also known to impair co-ordination, and can cause nausea and vomiting as well as anxiety and paranoia, which, with long-term use, may become chronic.
Medicinal use of cannabis is illegal and therefore there is little verifiable evidence of the drug's effects when used in the management of chronic health conditions. However, cannabis is widely used illegally for medicinal reasons, often for the relief of pain or as an appetite stimulant. In 1996, a clinical trial in San Francisco found that people with HIV wasting disease who used cannabis were more likely to put on weight. In 2007 a study found it helped relieve the pain caused by perihperal neuropathy in people with HIV. The drug is also widely used to relieve insomnia and the symptoms of anxiety and stress. It is also used by people with multiple sclerosis as a muscle relaxant.
In recent years a small number of people have been prosecuted for growing and consuming cannabis for medicinal purposes. In most cases a suspended sentence has been issued, but recently a jury returned a not guilty verdict, and in another example a judge threw out the case.
Cannabis extracts, called cannabinoids, are legally used in licensed pharmaceuticals, mostly painkillers and muscle relaxants, but these can only be obtained on prescription. These products do not make users feel ‘high' or have any of the other narcotic effects of cannabis.
Short-term risks of cannabis use include anxiety, panic, and paranoia. Memory and attention may also be affected, as might the ability to drive or operate machinery. Research suggests that cannabis use in teenagers is a predictor of later mental health problems. Use during pregnancy has been associated with low birth-weight babies.
If the drug is smoked, long-term use is known to cause many smoking-related respiratory and cardiovascular diseases such as asthma, bronchitis, emphysema and heart disease. This may be of particular concern to people with HIV who have suffered lung damage from TB, or to those with increased lipids from anti-HIV medication, as this may increase the risk of heart attack. There is also evidence that smoking cannabis can cause cancers of the mouth, throat and lungs.
Chronic loss of memory and shortened attention span have been observed in long-term users of the drug, in some cases even after their use has ceased, and there is evidence that long-term users can develop psychological dependency on the drug. In a recent survey, daily use of cannabis by teenagers was found to substantially increase the risk of developing depression later in life and the use of cannabis has also been linked with an increased risk of schizophrenia.
It is not known how cannabis reacts with anti-HIV drugs. A small American study found that cannabis use did not impact on the effectiveness of the protease inhibitor indinavir (Crixivan), even though the drugs use the same mechanism to pass through the body. Like any mood- or consciousness-altering drug, cannabis may have an impact on people's ability to adhere to their medication schedule. People planning to use cannabis, or any other recreational drug, may need to develop strategies to help them take their medication at the right time and in the right way.
Along with most other recreational drugs, government statistics suggest that more people are using cocaine (coke, charlie, snow, powder, marching powder) and the cocaine derivative, crack (freebase). In the UK, both cocaine and crack are illegal class A drugs. Dealing carries a maximum penalty of life imprisonment and unlimited fine, and possession can mean up to seven years in prison and a large fine.
Cocaine is a stimulant made from the leaves of the South American coca shrub. It comes in the form of a white powder, costing between £30 and £100 per gram. Usually snorted into the nose, it provides a feeling of excitement, exhilaration and self-confidence lasting for about 15-30 minutes. Cocaine can also be rubbed into the gums and into the anus or vagina before penetrative sex. Rarely, cocaine is also made into a solution for injection.
Crack is sold in the form of small rocks, which are smoked either in cigarettes or in a pipe. Historically, crack has been associated with poor urban populations, but is in fact used by people from a wide social spectrum.
Cocaine users may take many doses to maintain the high, which can cause anxiety, paranoia and a tolerance for the drug, meaning that larger doses have to be taken to achieve a similar high. Although not addictive in the same way as heroin or opiates, users can become psychologically dependent on the transient high that cocaine provides and find that they suffer anxiety, depression or severe tiredness if they stop using the drug.
Longer-term use of both cocaine and crack can cause severe anxiety, clinical depression, psychotic episodes, aggression, weight loss and malnutrition. Both drugs have also been shown to cause potentially fatal heart problems including heart attack, angina, irregular heart beat and inflammation and enlargement of the heart.
In common with most other street drugs, users are rarely sold a pure form of cocaine. The drug is often ‘cut' with other cheaper drugs such as amphetamines (speed), talc or detergents, which can be poisonous or cause irritation, leading to infection.
Snorting cocaine can damage the membrane between the nostrils, leading to bleeding and eventual erosion. There have been reports that sharing snorting equipment may permit the transmission of hepatitis C virus. Rubbing cocaine into the gums, vagina or anus can cause ulceration, which could increase transmission of HIV or other sexually transmitted infections. Sharing injecting equipment also presents a risk for transmission of HIV, hepatitis viruses and other blood-borne infections.
Cocaine is not metabolised by the body in the same way as anti-HIV drugs, so there does not appear to be cause for concern about interactions between them.
Test-tube studies suggest that cocaine alters the functioning of the immune system in several ways, making immune cells more vulnerable to HIV. Experiments conducted in HIV-infected mice bred in laboratories found that mice exposed to cocaine had far fewer CD4 cells than mice not given the drug. This suggests that HIV disease may progress faster in regular cocaine users.
However, studies looking at regular cocaine use and disease progression in gay men have produced conflicting results. One study found no association, whilst another found that weekly cocaine use was associated with a greater risk of death. Because drug use may be an indicator of other social issues which may have a negative effect on health - such as poor access to health care, or other health problems - these types of studies can be difficult to interpret.
As with all recreational drugs, it is also wise to consider how use could impact on adherence to your HIV treatments. If you are worried about your recreational drug use, then your doctor or healthcare team will be able to refer you to an appropriate source of support.
Crystal meth (methamphetamine)
Also know as crystal meth, ice, tina, krank, or yaba, methamphetamine is a synthetic form of amphetamine, a stimulant drug.
Crystal meth has been popular on the US gay scene for over a decade, and there is concern that the drug may be becoming more popular amongst gay men in the UK and Europe. However, it is unclear just how widespread use of the drug actually is. A large survey of gay men in the UK found that fewer than half of one per cent of those sampled used the drug on a weekly basis, although HIV-positive men, particularly those with large numbers of sex partners, reported much higher levels of use.
Methamphetamine is a class A drug.
Methamphetamine can be bought as a pill, as powder to be snorted through the nose or injected, or in a crystal form – ice – which is smoked in a pipe.
Methamphetamine brings on a rapid feeling of exhilaration, a perceived sharpening of focus and heightened sexual desire.
Smoking crystals of methamphetamine causes a rise in body temperature, an increased heart rate and rapid breathing.
Paranoia, short-term memory loss, rages and mood swings have been recorded.
There is some evidence that use of methamphetamine can cause people to become ill because of HIV more rapidly, to take more time to recover from infections and to respond less well to HIV treatments. However, some people believe that this has a lot to do with users of the drug not taking their anti-HIV and other medication properly.
Rapid fall in CD4 cell count has been observed in methamphetamine users. However, as many users of methamphetamine have difficulty sleeping or eating properly, there may be other lifestyle factors involved in the quicker disease progression noted in some users.
Psychological dependence on the drug has also been reported, although it does not seem to cause physical addiction.
Taking large amounts of the drug can cause convulsions, problems with blood circulation, inability to breath, coma and death. However, deaths have been reported in people who have taken only small doses.
In the US there have been concerns about a link between the use of methamphetamine by gay men and unprotected sex, particularly when used in conjunction with drugs to treat erectile dysfunction, such asViagra and Cialis.
There has been a case report of an interaction between methamphetamine and the protease inhibitor ritonavir (Norvir), which is used to boost levels of all the currently recommended protease inhibitors. Methamphetamine is metabolised by the body using the same mechanism as ritonavir. Doctors also believe that inhaling poppers may make the interaction worse.
The use of any drug can interfere with normal sleeping patterns, affect appetite and interrupt routines. Some people have found that this is particularly the case with methamphetamine. If you are using the drug, it makes sense to consider how it might affect issues such as adherence to your anti-HIV medication. The drug has also been linked with an increased likelihood of having unprotected sex, so plan how to manage this.
Ecstasy (E, X) is an illegal class A drug. Dealing carries a maximum life prison sentence and unlimited fine, and possession up to seven years in prison and a £5000 fine.
Ecstasy has both stimulant and hallucinogenic properties. Its active ingredient is a synthetic drug called MDMA. Originally used in psychotherapy, from the late 1970s it started to be used on the club scene due to its ability to reduce inhibitions, give an energy boost, induce relaxation and give intense pleasure by releasing the neurotransmitter serotonin.
The drug is sold in tablet form and, less frequently, as a powder. After about 30 to 45 minutes, the drug gives an intense ‘high', which may last for several hours. Because the body becomes tolerant of the drug, people may end up taking larger quantities to induce similar feelings of euphoria.
Because ecstasy is illegal there have been no proper clinical trials looking at the risks of using the drug for people with HIV. The effects of ecstasy on the immune system and on HIV disease progression are therefore uncertain.
In 1996, a man who had recently started taking a combination of anti-HIV drugs, including the protease inhibitor ritonavir (Norvir), died after taking two and a half ecstasy tablets. An autopsy found that there was an unusually high amount of ecstasy in his blood, which may be partly explained by an interaction between the drug and ritonavir. Ritonavir boosts the amount of ecstasy in the bloodstream by between 200% and 300%, because the body uses the same process to break down both ritonavir and ecstasy.
Because other protease inhibitors (and non-nucleoside reverse transcriptase inhibitors [NNRTIs] and many other drugs) are metabolised using a similar process, there is a risk that ecstasy could interact dangerously with them, and there have been hospitalisations due to adverse reactions to ecstasy amongst people taking protease inhibitors.
If you've started a new treatment combination recently, the first four weeks, when your body gets used to the new drugs, are likely to be the riskiest time for interactions. Some doctors suggest that after this period, if you choose to take ecstasy, it may be safer to begin with a quarter or half a tablet first. This information is included here in order to help readers reduce risks, and has not been researched scientifically.
As with all recreational drugs, it is difficult to know what the ecstasy tablet you are using really contains. The doses found in street drugs are not controlled, and the ecstasy pill you buy might contain much larger quantities of the drug. Often, ecstasy will have been ‘cut' with other substances which could be poisonous, or with other drugs, usually amphetamines or LSD, but occasionally heroin.
In the short term, ecstasy can cause dehydration, headache, chills, eye twitching, jaw clenching, blurred vision, nausea and vomiting and, like many drugs taken to get ‘high', is commonly accompanied by a ‘come-down'.
People can have an allergic reaction to the drug, which can be fatal (though deaths related to ecstasy are very rare in comparison to the extent of its consumption). The drug has also been associated with heart and lung problems, dramatic increases in body temperature, kidney failure and liver damage. The potential liver toxicities of ecstasy and other recreational drugs are of particular concern to people with HIV, as liver damage can itself make you very ill as well as stopping the body from processing anti-HIV drugs properly.
Long-term use has been linked to poor mental health, depression, psychotic episodes and memory problems.
If you are using ecstasy or planning to do so, then think about discussing this with your doctor or another member of your health care team. Most are quite happy to discuss drug use and can provide helpful information on minimising risks.
As with all recreational drugs, it is wise to consider how use could impact on adherence to your HIV treatments or other areas of your health or life.
GHB (gammahydroxybutyrate) has recently become popular on the club scene, with users reporting an alcohol-like high with potent positive sexual effects. However, its possession and use recently became illegal after a series of deaths were associated with its use.
GHB affects the release of dopamine in the brain, causing effects ranging from relaxation to deep sleep and coma. The drug also lowers blood pressure and can cause breathing difficulties.
A case has been reported in which levels of GHB were increased to life-threatening levels when taken along with a protease inhibitor. A man who was taking ritonavir (Norvir) and saquinavir (Invirase) became deeply unconscious after taking a half-teaspoon of GHB. Doctors believe that the ritonavir and saquinavir slowed down the metabolism of GHB and caused a near-fatal reaction.
Ketamine is an anaesthetic that makes people feel detached from their immediate environment.
Since early 2006 possession of ketamine has been a crime. It comes in a white powder that can be snorted, dissolved or injected. It normally takes effect after about 20 minutes. The body heats up and users have reported a range of different experiences including an altered sense of their body, hallucinations, difficulty moving or even completely freezing. This is often called a 'K-hole', and involves difficulty communicating and even breathing and swallowing.
The effects of long-term ketamine use include memory loss and psychological disturbance. Several deaths have been reported due to the use of the drug in the UK. Although no specific interactions with anti-HIV medication have been reported, use of the drug could affect adherence to HIV medication.
LSD (lysergic acid diethylamide, often known as acid) is a Class A drug. It is taken orally and normally begins to take effect after about 30 to 60 minutes. Its hallucinogenic effects last up to eight hours, although some people report 'trips' lasting as long as 24 hours.
LSD is not thought to affect the immune system and no specific interactions with anti-HIV drugs have been reported. However, when 'tripping' on acid adherence to anti-HIV medication might be difficult or even impossible.
These include heroin and methadone and are made from the opium poppy. Heroin is a Class A drug. Methadone is controlled by the Medicines Act.
Opiates are normally injected, smoked or sniffed. They depress the nervous system and have a euphoric effect. Tolerance of opiates develops quickly, as does dependence.
Use of opiates can cause chest problems and constipation. Sharing the equipment used to inject opiates can lead to infection with tetanus, hepatitis B and C, HIV, and can cause blood poisoning and abscesses.
Use of opiates can lead to malnutrition and self-neglect.
Methadone is a form of opiate normally supplied on prescription to registered addicts as an alternative to injecting. It is usually taken as a liquid. To withdraw from opiate use, addicts can gradually reduce their dose of methadone over a long period of time.
Methadone interacts with anti-HIV drugs. The drug is known to increase levels of AZT (zidovudine, Retrovir) in the blood. Doctors are often very cautious about giving protease inhibitors to people taking methadone, and will often admit them to hospital for observation for a short time. The protease inhibitor nelfinavir (Viracept) reduces methadone levels. The non-nucleoside reverse transcriptase inhibitors (NNRTIs) have differing effects on methadone levels. Nevirapine (Viramune) increases levels of methadone, whereas efavirenz (Sustiva) reduces levels of methadone, particularly in the early stages of treatment.
There is conflicting evidence about the effect of using opiates on HIV disease progression, with some studies finding that heroin users progressed to AIDS and death faster, while others did not. Since the advent of HIV treatments, some evidence has emerged that opiate users become resistant to their anti-HIV drugs faster, probably due to poor adherence.
Poppers are a nitrite-based drug. Amyl nitrite is used medically to ease the chest pain caused by angina. The drug gets its name from the small glass capsules containing amyl nitrite for the treatment of angina which used to be ‘popped’ under the nose and inhaled. Amyl and butyl nitrite started to be used recreationally, and have been popular with gay men for many years. More recently, they have become popular with clubbers of all sexualities.
In the UK, poppers are sold in small bottles, which contain a liquid form of butyl nitrite. It is very rare for amyl nitrite to be used as poppers, as its sale is illegal without prescription under the Medicines Act. The legal status of butyl nitrite has been the subject of court cases in recent years. The sale of butyl nitrite poppers is legal, largely because they are sold as ‘aromas’ or ‘room odourisers’ rather than as a drug to be inhaled. The possession of poppers, in either amyl or butyl nitrite form, is legal.
When inhaled, poppers cause blood vessels to dilate, allowing more blood to reach the heart. They also cause blood to rush to the brain, speed up heartbeat and relax muscles, providing an intense high lasting a few minutes at most. The drug is widely used to intensify pleasure whilst dancing and having sex. Sniffing poppers relaxes the anal sphincter muscles, allowing anal sex to take place more easily. As poppers dilate blood vessels, many men find that they lose their erection when sniffing them.
After-effects of sniffing poppers may include headache, skin rashes, weakness, sinus pains and burns if the liquid comes into contact with the skin. Sniffing poppers can also cause nausea and vomiting. People with heart or lung problems are advised to avoid poppers, as they can cause breathing problems. In very rare cases, excessive sniffing of poppers can cause the lips and skin to take on a blue tinge. This can be accompanied by vomiting and shock, and unconsciousness may follow. In extreme cases, deaths have been reported.
The long-term effects of poppers have been a matter of considerable controversy, particularly as it has been argued that their use caused AIDS and particularly Kaposi’s sarcoma. However, this view is not supported by any scientific evidence and studies comparing the effects of poppers on HIV-negative and HIV-positive gay men found that only those with HIV suffered any immune damage or progressed to AIDS. However, some animal studies have shown that poppers can suppress immune responses and can have cancer-causing effects. These studies have been criticised because of the relatively large amounts of nitrites given to animals. Any long-term immune damage or cancer-causing effect in humans remains to be proven.
There are no documented interactions between drugs used to treat HIV and poppers. However, sniffing poppers after taking the anti-impotence drugs Viagra and Cialis can result in a potentially dangerous, even fatal, drop in blood pressure. The dangers from sniffing poppers after taking Viagra or Cialis are increased if you are also taking a protease inhibitor as part of your HIV treatment. Protease inhibitors cause the amount of Viagra or Cialis in the blood to increase, and for this reason it is recommended that people prescribed protease inhibitors take only half the normal dose of Viagra or Cialis and do not use poppers at the same time.
As with any drug, it may be wise to consider how using poppers affects your wider health and lifestyle, particularly if you are using poppers with other drugs or alcohol. Some people report that using poppers may act as a trigger for unprotected sex and, if this is the case for you, you may wish to have a strategy in place to help you manage this.
Viagra (sidenafil citrate), Cialis (tadalafil) and Levitra (vardenafil) are treatments for erectile dysfunction that have become increasingly popular as recreational drugs, particularly amongst gay men, many of whom use the drug to counteract the impotence side-effect of other recreational drugs such as ecstasy. Several studies have linked use of Viagra and Cialis with increases in the amount of unprotected sex gay men are having and increased rates of sexually transmitted infections. However, it is unclear if this is because the use of these drugs enables men to have more sexual partners or just increases the amount of sex they are having. It’s also possible that men just add the use of anti-impotence drugs to their existing risk-taking repertoire.
The most common side-effect of these anti-impotence drugs is headache. Viagra, Cialis and Levitra should not be used in conjunction with poppers, as this could cause a potentially dangerous drop in blood pressure.
Protease inhibitors and NNRTIs are metabolised by the body using the same method as Viagra,Cialis and Levitra, and this can mean that you get very high levels of anti-impotence drugs in your blood, increasing the chances and severity of side-effects. For this reason, you are recommended to reduce by half the standard dose of both Viagra, Cialis and Levitra if you are taking either protease inhibitors or non-nucleoside reverse transcriptase inhibitors (NNRTIs), and not to take more than a single standard dose of these impotence drugs in a 48-hour period.