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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 02:01 1 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, 04:31 2 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 06:18 3 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, 4 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, 5 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.

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