Clinical Education Initiative [email protected]

ECHO: CHEM SEX Hansel Arroyo, MD

12/04/2019

ECHO: Chem Sex [video transcript]

00:10 Okay, so on the same vein of this case. My presentation is called Chem sex. Neo formerly club drugs.

00:21 I have no disclosures. Like I said, I'm the Director of Psychiatry and Behavioral Medicine at the Institute for Advanced Medicine and Surgery.

00:31 The objectives are

00:35 just for the use of club drugs in the context of sexual performance raves and circuit parties describe the most commonly used synthesized chemicals during Chem sex, and explore the additive properties and potential treatments of club drugs. Oh,

00:50 you know, let's just start with this idea that

00:53 like all things are poison, right, Paracelsus said this for there's nothing without poisonous quality is only the dose, which makes a thing poison. And this is a little bit of how I approach patients who come in with any sort of altering drug use

01:12 to not automatically define them as

01:18 psychiatric disorder, right, I do not automatically give them a diagnosis of substance abuse disorder, regardless of what substance is using, but really, it's the issue of functional impairment is this substance causing some functional impairment like in the case, the patient was very severely impaired without the drug, he was unable to function. He was completely isolated, had no you know, social interactions outside of the world of,

01:49 of drug use. He was lucky that he is very smart and was able to, like do the same kind of compartmentalizes work and not sort of end up

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essentially, like on the streets like many of our patients end up. So just to kind of keep that idea, right of like, what is the functional impairment? So, Chem sex or club drugs or is essentially any drug that is used to sort of enhance your sexual performance, it's often associated with parties rave or circuit parties. They're mostly synthesize chemicals. There is sort of as Poly club drug use rule, meaning that often people will use more than one drug at a time.

02:35 They're most of them have sort of like this classical addiction. I mean, sorry, crystal meth has sort of like this classical addiction part component, not a lot of the other club drugs do. And that's, you know, we're thinking about like poppers, MDMA, ecstasy, we don't normally see certainly that classic addiction that we associate with maybe alcohol, the obsession being crystal meth.

03:05 There are some adverse effect that's not common, and then it's, we see higher rates of MSM and HIV transmission associated with these clubs. I'll start with poppers. I have

03:19 several times I'm going to mention I'm going to leave out some that are a little more common and we might be familiar with so poppers so poppers are

03:29 are,

03:31 are drugs used for mostly for sexual performances. It's a it's very easily accessible. You can buy them at like in bodega, you can order them online. It's very surprising how like accessible on poppers are. They are

03:49 inhalants, they're highly lipophilic. They're rapidly absorbed through the lungs, they cross the blood brain barrier. They accumulates in the brain has a very rapid onset and short duration. And has often synergistic effect with alcohol and benzos.

04:08 Some of the acute effects of poppers are euphoria does inhibition, sense of lightheadedness, some slurred speech, ataxia is often noted drowsiness

04:23 it you know these can lead to increased incidence of accidents and injuries.

04:28 Historically,

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during like the AIDS epidemic, poppers were at one point thought to have some etiology in AIDS.

04:40 And I think there were at one point the 80s wanting to be banned, because they thought that it was part of what was causing HIV transmission. We see higher rates used of poppers within MSM, like I said it's enhances sexual perception and pleasure. It's often used to relax the renal sphincter

05:03 for anal penetrative sex, it causes vasodilation.

05:09 And it's,

05:11 like I mentioned higher risk of HIV transmission.

05:16 And it's often something that we don't

05:18 ask about.

05:21 You know, even I, in my practice, where the majority of my patients are MSM and living with HIV, it's something I still

05:30 often forget to ask about some of the adverse effects of poppers right, we have a see a really crusty yellow skin lesions around the face, hypotension tachycardia, headaches,

05:45 you know, we see this is a little bit rare and this has to do with

05:51 very heavy heavy use, sort of like methemoglobin the nitrite oxidize hemoglobin and you get like his methylene blue syndrome

06:04 so that's so that's poppers, there's no really any, any treatment for it. It doesn't have like I mentioned that sort of classical addiction is very linked to sex use very few people

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use poppers are exclusively or as their primary drug, it's often are sort of like this sort of poly drug substance use.

06:31 Let's move on to GHB.

06:35 And this, this is what is really interesting. When I wake up, I feel completely refreshed, in comparison to other drugs that are supposed to be clean, G, is really clean.

06:45 This might be something that we're more familiar and that patients may report more, more often. G, is,

06:56 is often a byproduct are we seen in use for other prescribing medication like Xyrem, which is to treat cataplexy and narcolepsy.

07:07 It's a it's a sexual enhancer. It's often use of parties very, like dose dependent. And

07:17 we normally see like,

07:19 like rave parties,

07:24 right sort of like describes they're similar to MDMA, resulting in, the greatest sex ever. It provides relaxation, tranquility, plus acidity, mild euphoria, and disinhibition. There's a mild temporary amnesia, it's often you know, physically, like known as like the date rape drug for this sort of, like amnestic effect.

07:48 So a little bit of a background of, of G, it's a, it's a precursor metabolite for GABA, receptor as we think of GABA receptors. When we think of GABA receptors as our receptors associated with anxiety, a lot of our benzos target GABA, a lot of our anti epileptics target GABA. Even our sleep drugs target target components of GABA receptors. So it has activity on both the GABA and the binding sites resulting in temporary suppression of dopamine, there's a subsequent marked release of dopamine and increased release of endogenous opioid, which is why we get this sort of mild euphoria mentioned that it's also highly regulated schedule three drugs xyrem.

08:34 The intoxication, it can be kind of like scary and dangerous, and it's very dose dependent. It's a steep dose response for it causes ataxia lessen of coordination, respiratory depression,

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bradycardia and can lead to coma and sort of these persistent vegetative states. And even death in overdose, especially like if mixing with other depressants, like alcohol, it has a synergistic effect

09:03 with alcohol and so I always educate patients of if they're using G or at a party not to mix it with alcohol and a lot of most of like the most already sort of like know that it's kind of like common in the community. Most people will just party with G but often if you had been drinking and

09:27 then moved to G, then you can see a lot of this potential risky side effects.

09:33 It's a medical emergency if somebody is overdose

09:37 and may lead to intensive care emergency admission, you know, use of age or pain, clearly,

09:44 for bradycardia a withdrawal, withdraw withdraw again, this is sort of stepping away from the classics.

09:56 of substance use sort of pattern why withdrawal is rare.

10:00 Mild withdrawal may persist for several weeks after cessation of use Usually,

10:05 we think of withdraws always as the opposite of what the drug causes were thinking anxiety, tremor, insomnia, through all these feelings of doom associated with panic attacks. Severe withdrawal resembles barbiturates, withdrawal and often treated with benzodiazepines.

10:27 Long term features, there can be some physiological dependence focusing to overdose on usually recovered completely. There is no FDA approved medications to treat and the major treatment modality within psychiatry has been CBT is the one that has shown the most

10:48 the most effects.

10:50 So if we think of now of cocaine, and methamphetamines, it's a bit going to be different from what we've seen with the G which is mostly a CNS depressant. It's what you know, like typically called a downer, cocaine and methamphetamines are more uppers. These are,

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11:10 we see a lot more release of dopamine when using

11:16 either of these two substances. And I'm going to compare the two.

11:21 You know, cocaine inhibits the re uptake of, of

11:26 synaptic dopamine, its effects usually lasts one or two hours, and that withdrawals can last up to like two days.

11:36 Whereas in math, it re inhibitory synaptic dopamine me, it promotes direct dopamine being released. So the effect that euphoric effect experience in meth is going to be substantially higher. And I'll show a graph later on of how much dopamine is actually released when using crystal meth. Which is why patients often experience this sort of euphoria they keep chasing, they can't no longer sort of get and why the crash is substantially longer as it is metabolized slower, right. And its effects typically last 10 to 20 hours were compared to cocaine, and the withdrawals can last several days. And so this is in my case, my patient would have like this crash after a weekend of binge that would last several, one or two days, where he was somewhat of a mobile nonfunctional couldn't really go to work and leave the house and sort of needed another round of like IV meth use to be able to kind of get up and be functional.

12:46 And withdraw often kind of mimics a very kind of severe depressive episode.

12:54 This, this slide is a little bit just like a reminder from,

12:58 you know, from physiology, just to kind of think about what the what are the effects of some of these stimulants like amphetamine and cocaine and what they do into our

13:09 reward system. So I'm just like, showing here sort of the effects of dopamine release in a reward system. And this is a little bit of what we try to address with pharmacologically. And what the theory behind the use of naltrexone in blocking someone's disease like

13:30 dopamine, and opioid receptors to sort of like break the pattern of cravings and wanting to use again.

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13:42 So, if we think of dopamine, and this is just a show, what are the the the effects of crystal meth? If you think of dopamine release, right? dopamine is sort of like our happy neurotransmitter, it gives us euphoria, sex drive, that sort of helps stabilize our mood.

14:00 You see, like here this graph, a basal dopamine output of something as pleasurable as food is around though, on the 150 right percentage, I think about sex,

14:13 the release of dopamine can go up to like 200 and then sort of, you know, kind of tapers off but it can be really high release

14:22 of dopamine and pleasure. If we compare it to other to some of the other drugs right alcohol around the 200 nicotine a little bit higher than the two and 250. It has a steeper curve which is why has to cost a lot of addiction because you get like a dopamine rush and then you lose it very quickly. Cocaine we go up to like the four hundreds.

14:49 And then

14:52 when you compare to the left, sorry, to the last

14:56 chart here, if you see amphetamines specifically

15:00 Crystal Meth in the dopamine release is way beyond the 1000s. So very like nothing

15:08 that people ever experienced. And that is why it's so highly addictive.

15:13 And then it drops off fairly quickly as well not as quickly as cocaine but it never really reached the dopamine release that cocaine did right in this and it does it again through blocking the re uptake of of dopamine but also promoting the release of dopamine in the central nervous system.

15:37 So that's a little bit of like what the, like biology behind this you know, crystal meth is often we use literally like meth labs that

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people synthesize with this sort of like at home comes in different forms, crystallize powder can be injected, it can be smoked.

15:59 And some of the effects right short versus long term effects. We have this sense of euphoria, sense of mastery, sexual arousal, appetite suppression.

16:10 And then long term effects that can be very problematic are seizures, hyperthermia, for medications, decreased appetite to the level of anorexia, people become psychotic and paranoid during the episode, and the withdrawal period is mostly a depressive type of picture, low energy, low mood hypersomnia that can be visual auditory and perceptual disturbances, hallucinations.

16:43 And during a sort of not, it doesn't happen to everybody. But if you get to this level of sort of like a psychotic presentation, it can be indistinguishable from schizophrenia, and very difficult to distinguish, especially in the ER setting.

17:00 We see some of the effects of sort of like the picking and the scratching and the sort of like itchy sensation that the long term use does.

17:12 Right, the damage that it causes to the teeth, especially smoking in in the level you know, when intoxicated I've mentioned this earlier euphoria, decreased appetite, very kind of hyper vigilant and somewhat paranoid.

17:30 can lead to seizures, the withdrawal will be the opposite right? dysphoria, increased appetite, fatigue, slowness, right? psychomotor retardation feeling very slow. I'm having vivid and unpleasant dreams hypersomnia is more common. Often, people sort of like sleeping for days, more insomnia can also occur. And, you know, this, this slide is very interesting. This is one of the research on meth use.

18:01 If when these some of these like long term effects, and I'm sure a lot of you have seen that patients even after they become achieve some level of sobriety, they still have this sort of lingering feeling of that withdrawal symptoms that I just mentioned. And the This slide shows the dopamine functions in the central nervous system. And you see when we compared to the top part, which is the normal controller brain, we look at the second one this is after one month of abstinence. So you see that there's lower function. And and we believe to be like lower dopamine production at that level you would have to one was abstinence. So patients can continue to experience this depressive picture, even one month. And if you compare it to 14 months of abstinence, you still have not a brain that looks similar to your normal control brain.

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So the effects can last up to over a year. When patients are feeling not like themselves nothing gives them pleasure stills are these lingering low energy and that is very important for us as physicians to address and even treat. I often treat this sort of

19:17 when patients are becoming abstinent from crystal meth I treat them as if they were having a depressive episode. You know we try to give them as this as it arise that they may boost their their dopamine because this feeling they can last after 14 months can lead to relapse.

19:38 I know that this is illegible I wait I try to zoomed in. But this is a I guess this is an interesting study that's tried to look at what are some of the treatments of crystal meth and on the and you know, john, this might be like interesting to you as well like on the left. We

20:00 See

20:02 the use of like amphetamines, sort of an agonist therapy and very, very little data we know things like using SSRIs neuroleptics,

20:13 anti seizure medication like Depakote Topamax.

20:19 It's unfortunate I can't be seen but you can kind of see like the things that have the most data which is still weak is the use of like Topamax naltrexone

20:29 and agonist therapy, meaning amphetamines prescribed amphetamines.

20:36 Many things have been tried to target to use

20:40 to treat crystal meth use Modafinil. A few years ago, people were really excited about the use of potentially using Modafinil, I still sometimes use it, depending on the patient that sort of like before, before I actually ended up giving this patient amphetamines I tried Modafinil first. But the data shows that it's not that great right or the Modafinil promise failed.

21:07 There was an idea of the cocaine vaccination that also did not go anywhere.

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And so there's really Unfortunately, there's like no real good treatment for crystal meth use. I think we're pretty much we're definitely more advanced when treating alcohol abuse disorders, nicotine abuse disorders. But for crystal meth, we really don't have any good good treatments.

21:35 You know, sort of like the Matrix Model, right? What are the things that we can do is essentially kind of throwing almost everything we have,

21:42 you know, group psychotherapy, individual family therapies, family is involved.

21:49 Sort of these AA, CMA groups,

21:53 definitely always treating co occurring disorders like depression or anxiety. There's always a lot of undiagnosed a ADD or ADHD and crystal meth users. You know, there's, there's something about what attracts you to the type of substances that you use, and a lot of patients who sort of kind of grab, gravitate towards using an amphetamine often have like an undiagnosed ADHD. And that is why like, when they use this drug recreationally, you sort of feel normal. So if that's the case, you know, kind of treating the co-occurrence ADHD

22:31 would be a good

22:33 this is just like a,

22:36 it's become very common, especially in the area, where, where I work, where it's sort of become very kind of common, and I think there's been a spike in crystal meth use in a lot of them, patient population.

22:52 Other other kind of, sort of like sexual enhancers that we often don't think about. I wanted to throw

23:01 you know, the use of sildenafil or like Viagra, that are often used to sort of like augments the sexual

23:10 experience. You know, crystal meth has a very close link to,

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like sexual activity. Often patients when they stop using, they are unable to have sex, they

23:30 get some form of ED, whether it's like a logic or physiological is more likely to be a combination of the both and they kind of connect the use of crystal meth with with having sex and not being able to have sex with a lot of crystal meth. And so things like Viagra are often used

23:49 you know, there was always like this study that show that after the introduction of it from 99, to have five new diagnosis of HIV and men having sex with men increased by almost 18% it's unclear of like that correlation

24:03 was like really

24:06 important to sort of mentioned, I think I'll end with ecstasy in the last like 10 minutes

24:14 ecstasy or MDMA.

24:18 It is a it's another type of form of stimulant it's also associated with release of dopamine. It comes into these very kind of fun looking pills.

24:32 You know, packages like plastic ziplock baggies or shampoo bottles.

24:37 Usually the methods of ingestion are orally It could also be crushes snort a very rarely cut sort of injected.

24:45 The most common use are orally and snorted every it's like most sort of stimulant it causes euphoria, empathic feelings or apathetic feelings.

24:59 Nervous is rough.

25:00 heartbeat, there's also teeth grinding.

25:06 People talk about like ecstasy versus MDMA and thinking of MDMA as being sort of like a more pure drug. Than the Nexus II, I mean, it's, it's unclear of like, what is the purity of, of any of

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these of any of these pills, like, you know, they're not regularly like tested or, or monitored. But you know, one studies show that the purity of it like berries, you know, 55 40%,

25:34 the the effects of MDMA, it's a party drug, right, the stimulant.

25:41 It's a hallucinogen, although not a lot of like patients report that.

25:47 It's sort of like an attenuated form of cocaine or attenuated form of like LSD kind of causes those sort of milder effects, increases empathy, profound feelings of restlessness

26:03 it was previously used for in the treatment of depression, and I think it gets rid of maybe people are looking at it again, for for those kind of euphoric empathic feelings in this 70s, it was definitely used a lot more frequently in psychotherapy.

26:20 So it releases not just like dopamine but it also releases serotonin. And that is sort of that is why we get that was a little bit of the idea of its antidepressant effects. And its association with this euphoria, empathic feelings.

26:38 So it blocks the re-uptake and it also causes releasing serotonin.

26:43 But the chronic use of it, instead of depletes your serotonin stores. So similarly to crystal meth, you end up with a picture of sort of this depressive kind of diathesis where patients are have very little pleasure don't

27:03 have very low energy have insomnia are sort of apathetic

27:08 because it also like inhibits the lessons of new serotonin

27:14 And intoxication, right. There was these

27:19 cases especially I think it started in the UK where we started seeing and then if you eventually in the US will be starting to see this pictures of like hypothermia, hyponatremia, dehydration during these raves, of people using

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27:35 MDMA, sort of like these, like long parties, warm rooms, people became very dehydrated and then overcompensating by drinking a lot of water.

27:48 And there were a couple of deaths and people like this arrive in a comatose state. The effect the immediate effect, right is wakefulness endurance, energy, decreases appetite, you get some of these hot flashes or die freezes, you can get a serotonin syndrome. So it's important to educate our patients of using

28:10 SSRIs or SNRIs, while you're kind of like typical antidepressants, when they're going out party, and how frequently they're using the

28:18 ecstasy or MDMA, because the release of serotonin can lead to this surge and into the can be very, it's it's a medical emergency

28:28 with a very similar picture of like the symptoms that I just described. And, you know, you treat it with hydration, cooling and sedation, not to use beta blockers which may worsen hypertension in these cases.

28:42 And then you also have to remove any serotonergic medication that the patient may be on at that point.

28:49 The withdrawal, right sort of like the opposite of the its effects and anhedonia, right lack of interest, a very persistent depressed mood, lethargy and fatigue,

28:59 people can become suicidal.

29:03 And there is no indication for treatment and just in the withdrawal period, long term effects of depression, anxiety, panic disorders, increase impulsivity, sleep disservices and cognitive dysfunction. Again, no FDA approved medications for treatment.

29:22 And the things that we see the most that are more effective are things like CBT, treating both for psychiatric conditions if they're present.

29:35 And I think for time, I think maybe I'll stop there.

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29:43 If anybody has like any any, any other any questions. [End Transcript]

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