04-10-17 Why Would Antiretroviral Drugs Be Abused?

Toxicology Question of the Week

April 10, 2017

Why Would Antiretroviral Drugs Be Abused?


     Over the last five years, antiretroviral (ARV) medications have gained popularity as recreational drugs. This misuse began in South Africa, which has the largest HIV/AIDS population in the world. Unfortunately, the abuse of this product has reached the United States (US) with reported use in Florida. Clubgoers in the Miami areas are using this very addictive drug and may not realize what the ingredients are as it is being sold as “cocktails”.  Grelotti, et al. (2014) interviewed HIV-infected people in this area and the users reported abusing ritonavir with 3,4-methylenedioxy-methamphetamine (MDMA) and methamphetamine for the enhanced and prolonged effects of the drug.  In addition, they use efavirenz alone for the euphoric effects- it does not require combined use with any illicit drugs.  

   Efavirenz (Stocrin) is the most popular ARV.  Users crush the pill into a powder and make a mixture using rat poison (strychnine), ARV’s, detergent and illicit drugs (heroin, marijuana, MDMA, phencyclidine (PCP) or cocaine).  The brown mixture has a vinegar smell and is usually sold in little plastic wrappers.  The drug is being smoked for the hallucinogenic effects and is called Whoonga, Wunga and Nyaopa.  Sadly, it is being utilized by people as young as 14 years old. 

     The most common adverse effect (52% of users) is central nervous system (CNS)/psychiatric disturbances. The drugs interaction with substrate and inhibitor versus inducer creates the preference for the most desireable ARV’s.  Non-nucleoside reverse transcriptase inhibitors (NNRTI’s)- nevirapine, efavirenz, protease inhibitors (PI’s)- indinavir and nucleotide reverse transcriptase inhibitors (NRTI’s)- zidobuvine, stavudine, lamivudine consistently penetrate into the cerebrospinal fluid (CSF).  Using these combinations will enhance the desired effects.  Grelotti, et al. (2014) has a great chart with the effects listed below: 

Substance

Effect of Combination with ARV's

Cannabis

Combination with efavirenz may heighten the euphoria of cannabis by CYP3A4 inhibition

Cocaine

No known effect in combination with ARVs

Heroin

No known effect in combination with ARVs

Oxycodone

Enhanced effect in combination with ritonavir by CYP2D6 inhibition

Methadone

Opiate withdrawal in combination with efavirenz or nevirapine by CYP3A4 induction

MDMA

Enhanced effect of MDMA in combination with ritonavir by CYP2D6 inhibition

Ketamine

Enhanced psychogenic effect of ketamine in combination with efavirenz and ritonavir by CYP2B6 inhibition

PCP

Enhanced psychogenic effect of PCP in combination with efavirenz or ritonavir by CYP3A4 inhibition

     Whoonga is number 2 on the list for homemade street drugs that are most devastating.  The feelings one experiences from consuming the drug only lasts about 2-4 hours.  It wears off in 6-24 hours and the user has terrible withdrawal signs and symptoms.  The unbearable abdominal pain, anxiety, backache, muscle cramps, depression, nausea and vomiting make the drug so addictive.  Addicts consume approximately 5 baggies of Whoonga daily to remain free from withdrawal.  Studies show people intentionally becoming infected with HIV/AIDS to obtain the ARV’s for free.  It is no surprise that Whoonga users have taken it to the next level since they are not concerned about becoming infected with HIV/AIDS. They are doing a “bluetooth” method.  This consists of a user injecting himself/herself with Whoonga to get high.  Next, they leave the needle in place and withdraw some of their blood.  Then, the blood is injected into someone else so they can also experience the high as well.  Below is a 1 minute you-tube video on Whoonga/Nyaopa/Wunga.

https://youtu.be/PVtx8oDILws

References:

Davis, G. P., Surratt, H. L., Levin, F. R., & Blanco, C. (2013, September 17). Antiretroviral medication: an emerging category of prescription drug misuse. Retrieved December 28, 2016, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956727/

Grelotti, D. J., Closson, E. F., Smit, J. A., Mabude, Z., Matthews, L. T., Safren, S. A., . . . Mimiaga, M. J. (2015, March). Whoonga: Potential recreational use of HIV antiretroviral medication in South Africa. Retrieved December 28, 2016, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3926908/

H. (2015, December 20). Top 10 Deadliest Street Drugs & Their Effects. Retrieved December 28, 2016, from https://www.youtube.com/watch?v=1Is6CAvnqwg

Knox, R. (2012, December 18). Dangers of 'Whoonga': Abuse of AIDS Drugs Stokes Resistance. Retrieved December 28, 2016, from http://www.npr.org/sections/health-shots/2012/12/18/167523601/dangers-of-whoonga-abuse-of-aids-drugs-stokes-resistance

Nyaope / Whoonga. (2016, December 07). Retrieved March 20, 2017, from http://www.mobieg.co.za/articles/addiction/types-of-drugs/nyaope-whoonga/

Software Informer - Micromedex Healthcare Series Browser ... (2016). Retrieved March 24, 2016, from http://micromedex-healthcare-series-browser.software.informer.com/

10 Most Devastating Homemade Street Drugs. (n.d.). Retrieved March 20, 2017, from http://www.bestcounselingdegrees.com/10-most-devastating-homemade-street-drugs/

This Question prepared by: Renee Miller, DNPc, MSN, RN, CSPI

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