Washington Blade - November 2, 2001
Eric Erickson

And now, some health officials are sounding an alarm: On Monday, a Board of Supervisors panel in San Francisco discussed an ordinance requiring businesses that sell poppers to post warning signs about possible dangers of using the nitrate-based liquid as a drug.

If approved by the Board of Supervisors, it would mark a return to enforcement of an ordinance on the books since the 1980s that calls for misdemeanor penalties for any business that did not post the warnings.

Other health officials and AIDS experts also warn that using the drugs -- individually or in combination -- can lead to an increase in risky sex at a time when HIV and other sexually transmitted diseases are making a resurgence among gay men.

"It's an interesting conundrum," said Jeff Smith, peer counseling program manager at AIDS Survival Project in Atlanta. "A lot of people are saying, `Is it that Viagra is making people have more risky sex, or are people who are already having high-risk sex just seeking out more Viagra?'"

The drugs

Viagra, a prescription drug used to offset erectile dysfunction, is quickly gaining the reputation as a popular club drug, allowing men to have longer sexual experiences when other substances render them temporarily impotent. Many gay men use Viagra for its intended purpose: an answer for persistent erectile dysfunction.

Also seeing an increase in use are alkyl nitrates, known socially as "poppers," which some men use to heighten sexual experiences by relaxing their bodies after inhaling.

Some medical professionals warn that using poppers and Viagra simultaneously can lead to dangerously low blood pressure, stroke, heart attack or death. Poppers, liquid amyl nitrate or butyl nitrate found in small brown bottles, are often sold under the guise of video head cleaner and can be found at gay novelty stores, bars, adult video stores, bath houses and on the Internet.

The San Francisco Public Health & Environment Committee, a panel of the Board of Supervisors, is considering reviving the health warnings about poppers to help educate people, said Tom Ammiano, president of the San Francisco Board of Supervisors, who is gay.

"To me, it seems reasonable," Ammiano said. "There could be a possible risk, so you would have an informed consumer."

The ordinance requiring businesses to post such warnings about poppers has been on the books since 1983, but has rarely, if ever, been enforced.

Viagra's popularity has helped make it a popular drug for recreational use, but some gay men use it for its intended purposes, said Tony Braswell of AID Atlanta.

After hearing from local public health officials, Ammiano said the committee decided to make a recommendation to the full board "calling for the formation of a work group made up of the District Attorney's Office and the Department of Public Health to see what it would take to reinstitute the program."

Ammiano said the panel has received verbal support from owners of local bath houses and sex clubs, where poppers are commonly used.

Gene Adams, manager of Club New Orleans, a private men's club with companion facilities in several cities across the country, said they only started selling poppers again two years ago, but have seen them enjoy a surge in popularity.

"It's picking up, but I don't think it's like the old days," Adams said. Poppers were much more popular at Club New Orleans during the '70s and '80s, he added. Adams said he would support a move to post warning signs next to poppers. In fact, he said popper manufacturers have already started posting their own warnings.

"The company I order from just put a notice on their flier that says `Viagra users, it has been found that some products in this catalog, in conjunction with Viagra, can be fatal,'" Adams said.

Knowing the risk

The combination of Viagra and poppers is dangerous because the two drugs affect the human body in about the same way, lowering a person's blood pressure, according to Dr. Jeffrey Klausner, the director of sexually transmitted disease prevention at the San Francisco Health Department.

Alkyl nitrates relax the body's smooth muscle tissue while enlarging blood vessels, Klausner said.

"The vessels get larger and that lowers your blood pressure and that lowers the amount of blood that goes through your heart and into your brain," he said.

"That's what the amyl nitrate does, and that's a similar mechanism to what the Viagra does. It improves blood flow to the penis. So these two things, working in a similar way, cause an overdose of this effect and people have extremely low blood pressure," he said.

The drop in blood pressure sometimes provides enough of a scare to prompt users to shy away from the combination.

"The poppers had worn off a little bit and the Viagra is still kicking, but you're not getting that high from the poppers," said a 33-year-old Atlanta gay man who used poppers after taking a half-pill of Viagra during sex. "It kind of starts all along your scalp line, that's kind of the first feeling, and then it goes down your body. For me, it made my chest warm and tight, like a lot of blood was stuck there."

He has taken Viagra when other recreational drugs have made it difficult to maintain an erection. But he doesn't plan on mixing Viagra with poppers again. "I knew that there was a risk of stroke," he said. "I learned from my mistake and consider myself very lucky."

Effects of the mixture

Some HIV educators aren't as worried about the combined effects of Viagra and poppers as they are about how the drugs might affect sexual behavior. As Viagra is becoming a more popular "club" drug, it is often being used with illegal drugs, including Ecstasy, methamphetamine or GHB, all designer drugs known to decrease sexual inhibitions.

"We know unprotected sex goes on when you mix poppers or other drugs together," James Loyce, deputy director of health for AIDS Programs at the San Francisco health department, told the San Francisco Chronicle. "It's a lethal cocktail."

A recent survey of more than 800 men visiting an STD clinic attached numbers to the arguments of some health workers that Viagra and other drugs used as party favors by gay men may feed HIV infections.

Some 32 percent of the gay respondents said they had used Viagra in the past year, compared to 7 percent of those who are heterosexual, according to the San Francisco health department, which conducted the survey.

Many of the gay men said they combined it with Ecstasy and other recreational drugs.

The gay men who reported using Viagra also reported more sexual partners than gay men who did not use it and they were more likely to have an STD, according to the survey.

Some 30 percent of gay Viagra users who were HIV-negative said they had unprotected anal sex with HIV-positive partners or men of unknown HIV status. That compared to 15 percent of gay HIV-negative men who had not used Viagra.

"The combination of decreasing the inhibitions of people and the self-control, people would be more likely to do risky behaviors, and with Viagra, they'll be more able to perform a sexual act and be at a higher risk to transmit the HIV disease," said Dr. Phillippe Chiliade, a physician and HIV expert at Whitman-Walker Clinic.

Michael Cover of Whitman-Walker Clinic: 'We're taking a look at our own level of prescriptions of Viagra.' (by Clint Steib)

Tony Braswell, executive director of AID Atlanta, an AIDS service organization, said that many men use Viagra for legitimate medical reasons or because certain HIV therapy medications have made it difficult for them to maintain an erection.

"Both are part of a complicated set of issues that we have to deal with as far as sexually transmitted diseases," Braswell said.

But he said the popularity of Viagra has made it easier for people to get their hands on the drug. The San Francisco survey showed that more than half of the respondents had gotten Viagra from a friend and not a doctor.

Even more dangerous, Chiliade said, is how Viagra can react to certain HIV cocktail therapies. He said that Retinovir can raise the level of Viagra in a person's blood to dangerous levels.

Klausner said that highly active antiretroviral therapies, known as HAART, can block the metabolism of Viagra.

"If someone was to take a normal dosage of Viagra while being on those medications without being under a doctor's medical care, they would overdose. And an overdose of Viagra will kill you," Klausner said. "Instead of taking 50 milligrams, it might be as if they took 500 milligrams."

The recreational use of Viagra prompted Whitman-Walker Clinic to rethink its position on the drug, said Michael Cover, associate executive director of public affairs for the Clinic.

"We're taking a look at our own level of prescriptions of Viagra and looking at a policy of providing important information about the use of Viagra along with other drugs and the dangers associated with those," he said.

Klausner said he hopes the results of the recent survey will prompt Pfizer, Viagra's manufacturer, to create an educational campaign for gay men about the drug.

Calls to the public affairs department at Pfizer were not returned by press time.

But a Pfizer spokesperson, Geoff Cook, told the New York Times last month that the company has long warned against the use of Viagra for non-approved purposes.

"Our position to not use Viagra for recreational purposes is well known, but any pharmaceutical product can be abused," Cook told the Times. Pfizer also advises caution when Viagra is used with protease inhibitors, he said.

The lure of poppers

Some of the same questions that surround recreational use of Viagra -- does use of the drug recreationally lead to more risky sex, or are gay men who engage in unsafe sex more likely to use the drug? -- can be asked of poppers.

"I really think alcohol would be more impairing to judgment than a hit of poppers," said Adams, the manager of Club New Orleans. "I think more people are crazier when they're doing their drugs or alcohol than when they're on poppers."

Adams added most men use poppers well into the sexual experience, usually close to orgasm.

"At the point that most people use [poppers], hopefully, the condom's already applied," Adams said.

Braswell agreed, adding a judgment call concerning condom use will most likely not be made during the high from alkyl nitrates.

"People who don't use condoms are not using condoms because of a judgment call that's really based on a much more intense substance, like alcohol or an illegal drug," Braswell said. "You don't make a decision in 90 seconds when the poppers wear off. It's a chemical that's bad for you, but I can't sit here and tell you it's the root cause of AIDS."

But in the early days of AIDS in the 1980s, use of poppers was considered a contributing cause to HIV infection.

When some gay men were being diagnosed with a very rare form of skin cancer, Kaposi's sarcoma, and its large skin lesions appeared, some health professionals argued that poppers caused KS -- because poppers increase the size of blood vessels at the skin level -- and in turn, HIV.

The speculation led to public controversy surrounding alkyl nitrates, which in turn, led to the inhalant's loss in popularity. Today, as the nitrates regain their popularity, health professionals find it difficult to say definitively whether poppers are dangerous.

"The literature on poppers is all over the map," Braswell said. "It's a foreign chemical, so it's not good to introduce into your body. But our concern as educators is that people would use it to try to stretch their body beyond limits that were safe."

Smith, the program manager for AIDS Survival Project in Atlanta, said he tries to stay away from scare tactics when educating people about any drug, including poppers or Viagra.

"Rather than telling somebody, `No, you shouldn't do this,' we try to educate people more to where they will be able to use them more wisely and be aware of the side effects," Smith said. "I think it's really important not to try to scare people, because I think a lot of people are sick of the scare tactics."

More dialogue urged

Steve Morin, director of UCSF's AIDS Policy Research Center, said the best way to combat abuse of drugs that may lead to risky behavior, including poppers and Viagra, is to talk about the issue.

He conducted a recent study that showed gay men are rarely talking about HIV and sex with their friends.

INFO

Whitman-Walker Clinic 1407 S Street, NW Washington, DC 20009 202-797-3500 www.wwc.org AIDS Survival Project 159 Ralph McGill Blvd NE, Ste 500 Atlanta, GA 30308 404-527-3621 www.aidssurvivalproject.org AID Atlanta 404-870-7700 1438 W. Peachtree NW Suite100 Atlanta, GA 30309 www.aidatlanta.org

"People feel less social support for staying negative," Morin said. Morin said his study showed a shift in community norms from safe sex being the norm to unsafe sex being an accepted option.

"Without a frank discussion in the community with your friends about HIV and what the consequences are, it's very easy to have that community norm shift over time," he said.

Klausner said that communication should continue between patients and physicians, especially about the misuse of Viagra and poppers.

"They should be informing their physician about any kind of drug, over-the-counter, prescription drugs, illegal drugs, that they're using," Klausner said. "A good doctor will not be judgmental. A good doctor will be thankful for the openness of the relationship and should be educating patients on how to use drugs safely."

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