An observed rise in γ-hydroxybutyrate-associated deaths in London: Evidence to suggest a possible link with concomitant rise in chemsex

Changes in the rates and characteristics of gamma hydroxybutyrate (GHB)-related death in Australia, 2001-2023

INTRODUCTION

In recent years gamma hydroxybutyrate (GHB) use appears to have increased. This study aimed to determine: (i) population rates of GHB-related death in Australia, 2001-2021; and (ii) whether there have been changes in the characteristics of GHB-related death in Australia over the period 2001-2023.

METHODS

Retrospective study of all Australian cases in which GHB was a mechanism contributory to death retrieved from the National Coronial Information System (n = 217). Joinpoint regression models were used to analyse trends in overall rates.

RESULTS

Death rates were stable between 2001 and 2015 ('stable period') (annual percent change [APC] = 3.7) but showed marked acceleration between 2016 and 2021 ('accelerated period') (APC = 44.4). Circumstances of death were: unintentional toxicity (81.6%), intentional toxicity (5.1%), self-harm (6.0%), traumatic injury (7.4%). Compared to the stable period, later cases were slightly older (34.2 vs. 30.7 years, p < 0.05), less likely to be employed (odds ratio [OR] 0.4), but more likely to have substance use problems (OR 3.9), a history of injecting drug use (OR 3.5), mental health problems (OR 3.6), and to have present in their blood at toxicological screening opioids (OR 3.2) and hypnosedatives (OR 3.7). The median blood GHB concentration was 170 mg/L, (range 0-3210), which did not change significantly. There were no differences in major organ pathology, but the proportion with aspiration pneumonia declined (OR 0.4).

DISCUSSION AND CONCLUSIONS

GHB-related death rates increased from 2016, accompanied by changes in case characteristics. In recent years GHB use appears to have extended to a population more likely to have substance use problems and use other respiratory depressants.

Trends in reported GHB-related presentations to Sydney emergency departments between 2012 and 2021

OBJECTIVES

In overdose, gamma-hydroxybutyrate (GHB) and its precursors can cause decreased levels of consciousness, coma and death. Here, we aim to describe reported exposure to GHB at four EDs in Sydney, New South Wales (NSW), Australia.

METHODS

We searched the ED databases of four Sydney metropolitan hospitals for presentations relating to GHB exposure between 2012 and 2021. We calculated annual number of presentations stratified by hospital, age, sex, mode of arrival and triage category.

RESULTS

A total of 3510 GHB-related presentations to ED were recorded across the four hospitals. Data for all hospitals were only available from 2015 onwards and between 2015 and 2021; there was a 114% increase in annual presentations (from 228 to 487). Males represented 68.7% of all presentations and the median age was 31 years (range 16-74 years). There was an increase in the proportion of female presentations between 2012 and 2021 (from 27.9% to 37.9%) along with the severity of presentation over the same period, with the proportion of presentations with a triage category 1 increasing from 19.7% to 34.5%.

CONCLUSIONS

Increases in recorded absolute number and severity of GHB-related presentations to Sydney EDs are a major public health concern. There may also be shifts in the demographics of those with GHB-related presentations. Renewed efforts are required to understand the drivers of these increases to optimally target harm reduction approaches.

Developing a coordinated response to chemsex across health, justice and social care settings: expert consensus statement

SUMMARY

Chemsex occurs primarily among gay, bisexual and other men who have sex with men (GBMSM), and there is evidence of a subgroup of users who carry out chemsex-related criminal offences and experience harm. Challenges with chemsex can present to various settings; there are concerns that harm is increasing, including at interfaces between health, social care and criminal justice systems. The UK response to date has lacked a coordinated approach. An expert reference group was convened to share chemsex knowledge, articulate priorities for research and pathway development, and foster collaborative working between agencies. It made three key recommendations: develop and increase training and awareness across all services; implement a coordinated research programme with the development of a common data-set and assessment tool to fully characterise population-level needs; develop a professional network to share information, provide professional support and act as a knowledge hub. There was support for a unified multi-agency strategy incorporating the priorities identified as overarching principles.

The interest of using vitreous humor for γ-hydroxybutyrate (GHB) quantification in related fatalities: Stability evaluation, case report and literature review

Analysis and interpretation of the findings for γ-hydroxybutyrate (GHB) in related fatalities remains problematic. Indeed, GHB is a naturally occurring compound present in both the mammalian central nervous system and peripheral tissue. Moreover, a postmortem increase in endogenous GHB concentration has been observed, especially in blood. Facing this issue, the use of an alternative matrix such as vitreous humor (VH) can thus be particularly interesting for GHB testing and quantification. VH is considered to be less prone to postmortem redistribution, is easy to collect, and has relatively few interfering compounds for the analytical process. In this context, the authors report the case of a GHB-related fatality involving 22-year-old male. In this case, GHB femoral blood (FB) (790 mg/L) and vitreous (750 mg/L) concentrations appeared similar with a FB to VH (FB/VH) ratio of 1.05. In addition, other similar cases with both GHB blood and vitreous concentrations were reviewed. Five cases were identified. The blood to VH ratios ranging from 0.13 to 2.58. Finally, GHB stability was documented in postmortem blood and VH, in order to address the reliability of VH as an alternative matrix for GHB quantitation at postmortem. GHB appeared relatively stable in postmortem blood specimens (at 50 mg/L) over a period of 28 days when stored at +4 °C or -20 °C. The same results were observed in VH specimens.

Understandings, attitudes, practices and responses to GHB overdose among GHB consumers

BACKGROUND

Gamma-hydroxybutyrate (GHB) is used at disproportionately high rates within sexuality and gender diverse communities and carries a high risk of overdose. GHB overdose can result in death. Internationally, recent increases in GHB overdoses have been observed. Coronial reviews of GHB-related death highlight the pivotal roles that bystanders to GHB overdose play in preventing fatality. No research has examined, in detail, how bystanders respond to GHB overdose. This qualitative study was conducted among people who use GHB and explored how they responded upon witnessing a GHB overdose experienced by someone else.

METHODS

Interviews were conducted with 31 sexuality and gender diverse Australian residents reporting three or more occasions of GHB use in the previous 12 months. Participants were asked questions about witnessed GHB overdose, their actions and decision-making processes throughout overdose. Data were analysed thematically.

RESULTS

Participants described witnessing GHB overdose, commonly in private settings involving sexualized GHB use. Variable definitions of GHB overdose were reported, ranging from GHB-induced symptoms of distress to comatose intoxication. Drastic actions to keep someone alert and responsive post-GHB ingestion were reported; these included the administration of stimulant substances and citrus. Decisions to call or not call for emergency medical services (EMS) were influenced by many circumstantial variables. In most instances, an EMS call was resisted and response practices deviated from established first aid protocols.

CONCLUSIONS

GHB overdose prevention and response training programs targeting people who use GHB are urgently required. These education interventions ought to address inaccuracies that inform street remedies for GHB overdose, teach people how to safely check breathing and response, promote basic first aid principles and address barriers to contacting EMS.

Drug behaviors, sexually transmitted infection prevention, and sexual consent during chemsex: insights generated in the Budd app after each chemsex session

Chemsex refers to the intentional use of drugs before or during sex in a specific context, typically involving prolonged sex sessions with multiple partners. Engaging in chemsex is associated with a wide range of health risks and related risk behaviors. We developed a mobile phone application ('Budd-app') to support and inform chemsex participants, reduce potential negative impacts associated with chemsex (e.g., physical, psychological and social health harms), and encourage more reasoned participation. During Budd's development process, 11 participants completed a survey after each chemsex session they attended. This data collection approach provided precise experiences on drug related behavior, prevention measures for sexually transmitted infection and sexual consent on 63 chemsex sessions. The mean duration of chemsex sessions was 17.5 h. Polydrug use was reported during 95% of chemsex sessions with an average of 3.5 agents per session. Unsafe dosing occurred at 49% of chemsex sessions, and 9/11 participants dosed unsafely at least once. Seven participants did not consistently take measures to prevent STI transmission. Nine had experienced peer pressure, both regarding drug use and sexual health. The same number reported sex without consent, not respecting others' boundaries as well as their own boundaries not being respected. Many participants experienced negative impact of their chemsex behavior during (7/9) and after (8/9) chemsex. Through participants' behavior assessment during multiple chemsex sessions, 'within-person' variability can be clarified. This clarification provides valuable insights in personal, emotional and contextual vulnerabilities. These insights can direct an individualized care and support trajectory aimed at addressing those vulnerabilities.

Amphetamine-related intoxications in people living with HIV: An observational study in an emergency department in Barcelona (Spain) from 2018 to 2020

BACKGROUND

Stimulant drugs, particularly amphetamines, are more commonly implicated in drug-related deaths in people living with HIV; however, the clinical characteristics of amphetamine-related intoxication in people living with HIV are poorly described.

MATERIAL AND METHODS

We conducted a retrospective study in people living with HIV who were admitted for amphetamine-related intoxication to an emergency department of a teaching hospital between 2018 and 2021. Severe intoxication (SI) was arbitrarily defined as requiring admission to the emergency medical support unit and receiving medical treatment for ≥6 h.

RESULTS

In total, 170 male patients with a median age of 36.2 + 7.5 years were included in the study. A total of 77 (45.3%) individuals had mental disorders, and 120 (85.7%) had HIV-1 RNA suppression, with a median CD4 cell count of 696 (interquartile range 490-905). In total, 61 (37.9%) individuals were on ritonavir/cobicistat-based regimens. Presenting clinical syndromes included agitation in 60 (35.3%) subjects, anxiety in 37 (21.7%), psychosis in 27 (15.8%), chest pain in 26 (15.3%) and altered level of consciousness in 20 (11.7%). SI was observed in 48 (28.2%) individuals, 12 (7.1%) required admission to the intensive care unit, and two (1.2%) died. Altered level of consciousness (odds ratio [OR] 6.5; 95% confidence interval [CI] 2.2-18.9; p < 0.01), psychosis (OR 5.8; 95% CI 2.2-15.1; p < 0.01) and suicide attempt (OR 4.6; 95% CI 1.8-11.6; p 0.01) were associated with SI in the adjusted analysis.

CONCLUSIONS

Amphetamine-related intoxication causes high morbidity in people living with HIV. Healthcare providers serving these patients should consider incorporating harm-reduction measures in the prevention of amphetamine-related intoxication.

Understanding Attachment, Emotional Regulation, and Childhood Adversity and Their Link to Chemsex

Background: Although evidence shows that engaging in chemsex can be associated with poor mental health, little is known about the relationship between psychological factors and this type of drug use. We aim to explore associations between engagement in chemsex and several psychological variables (adverse life events, attachment styles, emotional regulation skills, self-care patterns) in a sample of gay, bisexual, and other men who have sex with men (GBMSM) with drug-related problems. Methods: A group of GBMSM engaged in chemsex (n = 41) and a control group of GBMSM (n = 39) completed an online survey to assess drug-related problems and the abovementioned psychological variables, in which both groups were compared. All analyses were adjusted for covariates showing significant differences between groups. Results: Compared to the control group, participants engaged in chemsex showed significantly higher frequencies of an avoidant-insecure attachment style and early adverse life events, regardless of all covariates (HIV status, job situation, and place of birth). Poorer emotional regulation and self-care patterns and a higher frequency of sexual abuse were also found in participants engaged in chemsex, though we cannot rule out the influence of HIV status on this second group of variables. Conclusions: Some people with drug-related problems engaged in chemsex might have suffered early adverse events and might have an avoidant-insecure attachment style. Moreover, those who have been diagnosed with HIV might show higher emotional dysregulation and poorer self-care patterns. These variables should be routinely evaluated in this population.

Using Intervention Mapping to Develop an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Development and Usability Study

BACKGROUND

Chemsex refers to the intentional use of drugs before or during sex among men who have sex with men (MSM). Engaging in chemsex has been linked to significant negative impacts on physical, psychological, and social well-being. However, no evidence-based support tools have addressed either these harms or the care needs of MSM who engage in chemsex.

OBJECTIVE

The purpose of this paper was to describe the development of a mobile health intervention (named Budd) using the intervention mapping protocol (IMP). Budd aims to support and inform MSM who participate in chemsex, reduce the negative impacts associated with chemsex, and encourage more reasoned participation.

METHODS

The IMP consists of 6 steps to develop, implement, and evaluate evidence-based health interventions. A needs assessment was carried out between September 2, 2019, and March 31, 2020, by conducting a literature study and in-depth interviews. Change objectives were selected based on these findings, after which theory-based intervention methods were selected. The first version of the intervention was developed in December 2020 and pilot-tested between February 1, 2021, and April 30, 2021. Adjustments were made based on the findings from this study. A separate article will be dedicated to the effectiveness study, conducted between October 15, 2021, and February 24, 2022, and implementation of the intervention. The Budd app went live in April 2022.

RESULTS

Budd aims to address individual factors and support chemsex participants in applying harm reduction measures when taking drugs (drug information, drug combination tool, and notebook), preparing for participation in a chemsex session (articles on chemsex, preparation tool, and event-specific checklist), planning sufficient time after a chemsex session to recover (planning tool), seeking support for their chemsex participation (overview of existing local health care and peer support services, reflection, personal statistics, and user testimonials), taking HIV medication or pre-exposure prophylaxis in a timely manner during a chemsex session (preparation tool), and contacting emergency services in case of an emergency and giving first aid to others (emergency information and personal buddy).

CONCLUSIONS

The IMP proved to be a valuable tool in the planning and development of the Budd app. This study provides researchers and practitioners with valuable information that may help them to set up their own health interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/39678.

Do ART and Chemsex Drugs Get Along? Potential Drug-Drug Interactions in a Cohort of People Living with HIV Who Engaged in Chemsex: A Retrospective Observational Study

INTRODUCTION

People living with HIV (PLWH) who engaged in chemsex are at risk of potential drug-drug interactions (pDDIs) with recreational drugs. This study aimed to characterize pDDIs between antiretroviral treatment (ART) and chemsex drugs and evaluate their association with unscheduled relevant hospital consultations.

METHODS

We conducted a single-center, retrospective, observational study in a series of gay, bisexual, and other men who have sex with men (gbMSM) living with HIV who engaged in chemsex and who attended a tertiary hospital in Barcelona, Spain, from February 2018 through August 2019. Associations between all recorded pDDIs and relevant unscheduled consultations were estimated using the incidence rate (IR) per 100 person-years of those events compared between patients with no pDDI (green flag) or moderate severity pDDI (orange flag) with patients with high severity pDDI (red flag) using the incidence rate ratio (IRR).

RESULTS

Among 172 PLWH engaged in chemsex, 249 ART regimens were prescribed: 44% based on integrase inhibitors, 30% on boosted ART, and 26% based on non-nucleoside reverse transcriptase inhibitors. The substances and recreational drugs most frequently used were erectile dysfunction agents (83%), methamphetamine (79%), GHB (77%), and alkyl nitrites (71%). Polydrug use was reported in 52%. We observed 2048 pDDIs. Of these, 23% were orange flag pDDIs; 88% related to boosted ARTs. The IR of the 285 unscheduled relevant episodes in patients with orange flag pDDIs was 64.67 (95% CI 40.07-89.28). The IRR of green flag pDDIs was 1.05 (95% CI 0.60-1.8; p = 0.876).

CONCLUSION

One in four pDDIs were of moderate severity but no significant increase in the incidence of unscheduled relevant consultations was observed. A high number of unscheduled consultations, predominantly for psychiatric events and intoxication, were observed. Beyond using non-boosted ART to minimize pDDIs, other factors related to the practice of chemsex must be addressed, in order to offer a better approach.

Sexualized drug use among men who have sex with men in Madrid and Barcelona: The gateway to new drug use?

This original study compares the prevalences of drug use for any purpose and for sexualized drug use (SDU) among MSM. It also describes relevant characteristics of first SDU, analyzes to what extent SDU has been the first experience (the gateway) with different drugs by age and explores the correlates of SDU. Study participants included 2,919 HIV-negative MSM attending four HIV/STI diagnosis services in Madrid and Barcelona. They answered an online, self-administered questionnaire. Poisson regression models with robust variance were used. About 81.4% had ever used any drug, and 71.9% had done so in the last-12-months, while 56% had ever engaged in SDU, and 50% had done so in the last-12-months. Participants under 25 years old had the lowest prevalences of SDU, and the 25-39 age group the highest, except for Viagra, which was higher among those over age 40. The most frequently used drugs for first SDU were poppers (53.6%), cannabis (19.6%) and Viagra (12.2%). These drugs were also the most ever consumed for SDU. Among sexualized users, methamphetamine (78.3%) and Mephedrone (75.4%) were used always/most of the times for sex in the last-12-months. Around 72.2% of Mephedrone sexualized users and 69.6% of Methamphetamine vs 23.1% of ecstasy users' first consumption of these drugs involved use for sex. These drugs were provided to them free where they have sex for 66.8, 79.1, and 31.9%, respectively. On that occasion, 8.1% of Mephedrone, 6.8% of Methamphetamine and 18.4% of ecstasy users had sex only with steady partner; with 50.2, 56.2, and 26.2% respectively using a condom with any partner. SDU in the first use was associated with similar variables for recreational and chemsex drugs. The highest prevalence ratios were for having ever been penetrated by >20 men and having ever injected drugs. It can be concluded that the prevalence of SDU was more than half of the prevalence for any purpose. Thus SDU was the gateway to use for many drugs in an important proportion of users, who frequently consumed drugs that were free and had condomless anal sex with occasional and multiple partners. These circumstances were much more common for chemsex than for recreational drugs.

HIV, chemsex, and the need for harm-reduction interventions to support gay, bisexual, and other men who have sex with men

Numerous studies have identified an association between the use of drugs in sexual contexts (chemsex) and HIV among gay, bisexual, and other men who have sex with men (GBMSM), although whether a causal relationship exists is contentious. An intricate relationship exists between chemsex, HIV treatment and prevention, harm reduction, and the provision of community-grounded health services. Furthermore, potential harms exist beyond HIV, such as intoxication and overdose. Community-engaged responses to chemsex involve social and cultural strategies of harm reduction and sexual health promotion before, during, and after a chemsex session. Ultimately, this Review calls for actions and collaborations aimed at developing a greater understanding of chemsex as a practice within different GBMSM subpopulations and to develop tailored harm-reduction models that can accommodate GBMSM who engage in chemsex in various ways and with varied effects.

Chemsex users in Czechia: EMIS survey

OBJECTIVES

Chemsex is a phenomenon highly relevant to public health concerns. Our primary aim is to describe the Czech chemsex scene regarding substances used, sexual behaviour, mental health, sexual life satisfaction, internalization of homonegative attitudes, and prevalent chemsex patterns.

METHODS

The data from the European Men Who Have Sex With Men Internet Survey (EMIS) 2017 were used. The mental health of chemsex users was assessed by the Patient Health Questionnaire 4 (PHQ4), internalized homonegativity was measured using the Short Internalized Homonegativity Scale. A sample of 87 men who have sex with men (MSM) chemsex users and a comparison group of 261 MSM were selected from the total sample of 1,688 respondents. Mann-Whitney and χ² tests were used to compare groups.

RESULTS

Active chemsex users made up 5% of the sample (87 of 1,688), with an average age of 37 years. Chemsex users were more likely to engage in condomless sex with non-steady partners (χ² = 46.8, p < 0.001), and had dramatically more STIs, such as HIV (χ² = 52.9, p < 0.001), HCV (χ² = 25.9, p < 0.001), and syphilis (χ² = 41.5, p < 0.001). Chemsex users frequently injected drugs (n = 19, 20%). More than half (n = 48; 55%) of chemsex users had sober sex in the last 4 weeks. Chemsex culture was associated with riskier substance use, both in terms of mode and frequency. The mental health of chemsex users in our sample did not differ significantly from the comparison group (χ² = 0.2, p < 0.7). Chemsex users did not conceal their sexual identity more often than the comparison group, on the contrary, 69% (n = 59) of them were out to most significant others, compared to 53% (n = 134) in the comparison group (χ² = 8.8, p < 0.05). In addition, we did not find differences in the degree of internalized homonegativity (χ² = 0.9, p < 0.4). Chemsex users were clearly and significantly more satisfied with their sex life than the comparison group (Mann-Whitney U test, p < 0.001).

CONCLUSIONS

In our sample, chemsex use was not associated with a negative impact on health or wellbeing. Our results suggest that chemsex is not a homogeneous phenomenon. Many different patterns and subcultures exist, some of them are riskier, some safer than others.

Cognitive Impairment Following Clinical or Recreational Use of Gammahydroxybutyric Acid (GHB): A Systematic Review

BACKGROUND

GHB (gamma-hydroxybutyric acid; sodium oxybate) is a general anaesthetic that is clinically used for the treatment of narcolepsy, cataplexy, alcohol withdrawal and alcohol relapse prevention. In addition, GHB is recreationally used. Most clinical and recreational users regard GHB as an innocent drug devoid of adverse effects, despite its high dependence potential and possible neurotoxic effects. At high doses, GHB may lead to a comatose state. This paper systematically reviews possible cognitive impairments due to clinical and recreational GHB use.

METHODS

PubMed and PsychINFO were searched for literature data about the acute and residual cognitive deficits following GHB use. This review is conducted using the PRISMA protocol.

RESULTS

A total of 43 reports covering human and animal data on GHB-induced cognitive impairments were eligible and reviewed. This systematic review found no indication for cognitive impairments after clinical GHB use. However, it supports the view that moderate GHB use may result in acute short-term cognitive impairments, whereas regular high-dose GHB use and/or multiple GHB-induced comas are probably neurotoxic resulting in long-term residual cognitive impairments.

CONCLUSION

These results emphasize the need for awareness among clinicians and recreational users to minimize negative health consequences of recreational GHB use, particularly when high doses are used and GHB-induced comas occur.

Increasing emergency department admissions for chemsex-related intoxications in Barcelona, Spain, among people living with HIV: an observational study from 2018 to 2020

Background

Chemsex is a novel phenomenon referring to the use of drugs, including crystal methamphetamine, gammahydroxybutyric acid (GHB)/gamma-butyrolactone (GABA) and mephedrone, to facilitate, enhance, and prolong the sexual experience in men who have sex with men in large cities internationally. There is a growing concern about chemsex and fatal cases among people living with HIV on antiretroviral therapy. This study aimed to describe the clinical characteristics of chemsex-related intoxications.

Material and methods

An observational study was conducted in people living with HIV who were admitted for chemsex-related intoxications in an emergency department of a teaching hospital in Barcelona, Spain, from 2018 to 2020. Severe acute intoxications were defined according to the Poisoning Severity Score.

Results

One hundred and fifteen male patients with a median age of 35.6±7 years were included in the study:15 (13.1%) in 2018, 32 (27.8%) in 2019 and 68 (59.1%) in 2020. All patients had stable housing, 107(93.0%) were Spanish citizen and 32 (27.8%) had mental health disorders. Median CD4 lymphocyte count was 624 (500–765) cells/mm³ and 99 (86.1%) had HIV-1 RNA suppression.

Poly-drug use was observed in 51(44.3%) cases and methamphetamine in 75(65,2%) and gammahydroxibutiric acid in 68 (59.1%) were the main drugs used.

Potential drug interactions due to the inhibition of cytochrome P450 by antiviral therapy was determined in 36 (31.3%) patients. Severe intoxications cases affecting neurologic and respiratory systems were diagnosed in 12 (10.4%) patients and no patient died. CD4 cell counts ≤500 cells (O.R.:4.2; C.I.95%:1.2–14.6) and mental health disorders (O.R.: 2.9; C. I 95%: 0.8–9.9) were associated with severe acute drug intoxications in the bivariate analyses.

Conclusions

Chemsex-related intoxications are an increasing clinical problem in people living with HIV. Chemsex should be routinely screened and addressed in clinical practice, particularly for people with mental illness and low CD4 cell counts, who are at higher risk for severe intoxications.

Chemsex and antiretroviral prescribing in an HIV cohort in Brighton, UK

OBJECTIVES

Chemsex has been reported among men who have sex with men (MSM) living with HIV. There have been concerns about potentially harmful drug-drug interactions between chemsex drugs and antiretroviral therapy (ritonavir and cobicistat). We aimed to describe the prevalence and patterns of chemsex users in our HIV clinic population and to evaluate antiretroviral prescribing among chemsex users.

METHODS

We undertook a cross-sectional study of patients attending our HIV clinic between January 2019 and December 2020. We collected data on patients who disclosed recent recreational drug use including chemsex in the previous 3 months.

RESULTS

In all, 2202/2501 (88%) patients were asked about recreational drug use and 514 (23%) disclosed recreational drug use. Eighty-two (4%) of these disclosed recent chemsex; 73 (89%) used crystal methamphetamine, 51 (62%) used gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL), 55 (67%) reported poly-drug use and 63 (76%) reported injecting drug use. The chemsex users were all cis-male MSM and were significantly older (53 vs. 46 years, p < 0.0001), and more likely to have had previous syphilis (73% vs. 28%, p < 0.0001) than patients reporting non-chemsex drug use. All chemsex users were prescribed antiretrovirals and 74 (90%) had an undetectable HIV viral load; 31 (38%) patients were taking either ritonavir (N = 12) or cobicistat (N = 19) as part of their antiretroviral regimen and this was similar to other patients attending for HIV care [31/82 (38%) vs. 768/2419 (31%), p = 0.25].

CONCLUSIONS

The prevalence of chemsex users among our HIV clinic attendants is 4%, and 38% of these were prescribed either ritonavir or cobicistat. Chemsex use should be a factor in antiretroviral therapy decision-making to avoid potential harm.

Information-seeking behaviours in Australian sexual minority men engaged in chemsex

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Participants engaged in chemsex over long periods of time and on a regular basis.

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Most know where to seek professional help and access harm reduction information.

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Many worry about being judged by health professionals and few seek out assistance.

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Participants feel uncomfortable discussing chemsex with most health professionals.

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Information from sexual health professionals is trusted the most.

Introduction

Chemsex refers to using illicit substances to facilitate sexual experiences in men who have sex with men. Chemsex has been linked to significant negative impacts on psychological, social, and physical wellbeing. Little is known about information-seeking behaviours in this population. This study aims to provide an in-depth understanding of seeking and engaging with health information.

Methods

Self-identified Australian sexual minority men who engage in chemsex (N = 184) participated in an anonymous cross-sectional survey. Variables included chemsex engagement, knowledge, perception and use of harm-reduction information, and associated health and support services. Pearson correlation and ANOVAs were conducted. Wilcoxon-Signed-Rank and Friedman tests were applied to analyse the perceived trustworthiness of information sources.

Results

Chemsex represented a meaningful part of sexual events. Most participants knew where to access professional help and harm-reduction information but worried about being judged. Most did not feel comfortable discussing chemsex with health professionals except with sexual health doctors/counsellors. Few users discussed health risks with a professional. Information on chemsex was received through multiple sources with significant differences in perceived relevance and trustworthiness, with sexual health doctors/nurses ranked the most trustworthy information. Interest in non-traditional sources of information was low except for formal peer networks and anonymous personal expert advice.

Conclusion

Engagement with health professionals and harm-reduction information is limited in this population, despite high risk and potentially significant adverse health outcomes. Results suggest that new and combined approaches are necessary to reach this population, including peer support networks, anonymous personal advice and changing community attitudes towards chemsex.

Sex in Chemsex: Sexual Response, Motivations, and Sober Sex in a Group of Italian Men Who Have Sex With Men With Sexualized Drug Use

BACKGROUND

Most studies on chemsex focus on the health risks associated with the practice, whereas less attention has been paid to the perception of sexual gratification in men who have sex with men (MSM) who use these substances.

AIM

The purpose of this study was to explore the effects of chemsex substances on sexual response, motivations to engage in chemsex and the relationship with sober sex.

METHODS

Thirty-one Italian cisgender MSM involved in sexualized drug use were interviewed and transcripts were thematically analyzed.

OUTCOMES

An ad hoc grid exploring sociodemographic data, chemsex sexual experience, motives, and relationships with sober sex was used during telephone-based interviews.

RESULTS

Participants showed significant individual differences in how chems may affect their sexual experience. The most reported effects were an increase in sexual desire and subjective arousal, access to higher disinhibition, possible erection and ejaculation difficulties, significant extension of the sexual experience duration, and an intensified perception of intimacy and pleasure. All the positive outcomes of substances on sex creates a great curiosity around chemsex, which is among the primary motives to engage in chemsex for the first time. Over time, other motives may emerge, also connected to substance abuse and craving. Some men reported to be motivated by their partners and friends and to use chemsex to cope with depressive mood/anxiety symptoms, stress and sexual problems. Many differences were reported between chemsex and sober sex. Chemsex seems to embody the idea of transgressive and exciting sex, while sober sex is outlined as a more intimate encounter, that can be significantly affected by performance anxiety.

CLINICAL TRANSLATION

These results offer some new perspectives that may add interesting information to the literature and be fundamental for future prevention and harm-reduction projects.

STRENGTHS & LIMITATIONS

Although this study is based on a small group of Italian MSM and the interviews were not audio-recorded, transcripts were consistent with scientific literature that considers it important to pay attention to the positive links between sex and substance use.

CONCLUSION

The promotion of safer sexual behavior should contemplate an in-depth discussion and recognition of both pleasurable and distressing aspects of chemsex sexual experience, its motivations over time and perceived differences with sober sex. Nimbi FM, Rosati F, Esposito RM, et al. Sex in Chemsex: Sexual Response, Motivations, and Sober Sex in a Group of Italian Men Who Have Sex With Men With Sexualized Drug Use. J Sex Med 2021;XX:XXX-XXX.

Absence of drug-drug interactions between γ-hydroxybutyric acid (GHB) and cobicistat

OBJECTIVES

Potential interactions between CYP3A4 inhibitors and γ-hydroxybutyric acid (GHB) have been suggested as a possible explanation for cases of GHB overdose in recent years among people living with HIV engaged in chemsex. Our objective was to assess the effect of cobicistat on the pharmacokinetics of GHB.

METHODS

Fifteen healthy adults were enrolled in this randomized, double-blind, placebo-controlled, two-arm, crossover clinical trial. Participants underwent two 5 day treatment periods with at least a 1 week washout period between them. In each treatment period, participants received cobicistat (150 mg q24h orally) or matched placebo. On day 5 of each treatment period, participants were given a single oral dose of GHB (25 mg/kg). Plasma concentrations of GHB, subjective effects, blood pressure, heart rate and oxygen saturation were monitored for 5 h after dosing. GHB pharmacokinetic and pharmacodynamic parameters were calculated for each participant during each study period by non-compartmental analysis and were compared using linear mixed-effects models. The study was registered at https://www.clinicaltrialsregister.eu (Eudra-CT number 2019-002122-71) and at https://clinicaltrials.gov (NCT04322214).

RESULTS

Ten participants completed the two study periods. No drug-related adverse events that necessitated subject withdrawal or medical intervention occurred during the study. Compared with placebo, none of the primary pharmacokinetic parameters of GHB was substantially changed by the administration of GHB with cobicistat. Similarly, no differences regarding subjective or physiological effects were observed when GHB was administered alone or with cobicistat.

CONCLUSIONS

Neither pharmacokinetic nor pharmacodynamic drug-drug interactions between cobicistat and GHB were identified in this study.

Chemsex practice in France: An update in Addictovigilance data

BACKGROUND

Complications related to Chemsex practice (consumption of psychoactive substances in sexual context) were first assessed by the French Addictovigilance Network in 2014. In response to the deaths reported in 2016, a new expert report was commissioned to update the complications and evolution of Chemsex-related practices in France.

METHODS

Between January 2008 and August 2017, all Chemsex cases collected through the French Addictovigilance Network's epidemiological tools were analyzed. Comparison of data between two periods (before and after 2014) was performed to assess the evolution of practices.

RESULTS

Over the entire survey period, 235 Chemsex cases were identified, all of them in men, with a mean ± SD age of 39 ± 11 years, including 24 deaths (10.2%). An increase in the number of reported cases was observed from one in 2008 to 50 in the first 8 months of 2017. The main medical histories include human immunodeficiency virus (HIV; 45%) and hepatitis C (20%) infections, and substance use disorders (36%). In those 235 cases, 345 psychoactive substances were identified, mainly cathinones. Polydrug use was reported in 75% of cases. The main complications were substance use disorders (63%), acute neurological or cardiovascular intoxications (50%), various psychiatric disorders (39%), and viral and bacterial infections (18%). γ-Butyrolactone (GBL) was present in 95% of comas. An increase in the number of deaths was observed during the survey period.

CONCLUSION

The French Addictovigilance Network, via this pharmacoepidemiological surveillance, warns public health authorities in order to support harm reduction programs and the management of Chemsexers.

Chems4EU: chemsex use and its impacts across four European countries in HIV-positive men who have sex with men attending HIV services

Introduction

Chemsex in a European context is the use of any of the following drugs to facilitate sex: crystal methamphetamine, mephedrone and gamma‐hydroxybutyrate (GHB)/gamma‐butyrolactone (GBL) and, to a lesser extent, cocaine and ketamine. This study describes the prevalence of self‐reported recreational drug use and chemsex in HIV‐positive men who have sex with men (MSM) accessing HIV services in four countries. It also examines the problematic impacts and harms of chemsex and access to chemsex‐related services.

Methods

This is a cross‐sectional multi‐centre questionnaire study of HIV‐positive MSM accessing nine HIV services in the UK, Spain, Greece and Italy.

Results

In all, 1589 HIV‐positive MSM attending HIV services in four countries completed the questionnaire. The median age of participants was 38 years (interquartile range: 32–46 years) and 1525 (96.0%) were taking antiretroviral therapy (ART). In the previous 12 months, 709 (44.6%) had used recreational drugs, 382 (24.0%) reported chemsex and 104 (6.5%) reported injection of chemsex‐associated drugs (‘slamsex’). Of the 382 engaging in chemsex, 155 (40.6%) reported unwanted side effects as a result of chemsex and 81 (21.2%) as a result of withdrawal from chemsex. The reported negative impacts from chemsex were on work (25.1%, 96), friends/family (24.3%, 93) and relationships (28.3%, 108). Fifty‐seven (14.9%) accessed chemsex‐related services in the past year, 38 of whom (67%) felt the service met their needs.

Discussion

A quarter of participants self‐reported chemsex in the past 12 months. There were high rates of harms from chemsex across all countries, including negative impacts on work, friends/family and relationships. Although a minority of those engaging in chemsex accessed support, most found this useful.

We Have a Lot to Do: Lack of Sexual Protection and Information-Results of the German-Language Online Survey "Let's Talk About Chemsex"

Background: The prevalence of chemsex and sexualized substance use is increasing in several European countries, particularly among men who have sex with men. In this subgroup, illegal substance use is associated with increased sexual risk behavior, which can result in severe physical and psychological impairments. The present study examined the incidence and prevalence of chemsex in German-speaking countries. Methods: To further describe the high-risk group of Chemsex users, participants (N = 429) were asked about their psychotropic substance use, sexual and health-related behavior, health status, and socio-demographic information by using an online questionnaire. Whether Chemsex has negative effects on well-being was measured with the WHO well-being index. Of additional interest was how informed Chemsex users are about the topic and what needs are placed on the practitioners. The online questionnaire consisted of 105 items, and data was collected from March to May 2019. Thousand forty seven datasets were saved with a dropout rate of 59%, 123 completed questionnaires fulfilled the criteria for chemsex users (n =123). Results: There were no significant differences in well-being between chemsex users and non-users. All participants protected themselves against sexually transmitted diseases irregularly or not at all. The majority of chemsex users reported intermittently using illegal substances (ketamine, methamphetamine, mephedrone, γ-butyrolactone/γ-hydroxy butyric acid). They viewed their sexual and substance use behavior as problematic, but few showed motivation for behavior change. Chemsex users clearly expressed a need for more information and advice centers. Conclusion: The results provide information on chemsex users that can be used for the future development of a therapy manual and thus contribute to improving health care for this group. The prevalence of chemsex is increasing and urgently needs more research to protect clients from health impairments and stigmatization.

γ-Hydroxybutyric Acid-Ethanol Drug-Drug Interaction: Reversal of Toxicity with Monocarboxylate Transporter 1 Inhibitors

The drug of abuse, γ-hydroxybutyric acid (GHB), is commonly co-ingested with ethanol, resulting in a high incidence of toxicity and death. Our laboratory has previously reported that GHB is a substrate for the monocarboxylate transporters (MCTs), necessary for its absorption, renal clearance, and tissue distribution, including across the blood-brain barrier. Our goal was to investigate the drug-drug interaction (DDI) between GHB and ethanol and to evaluate MCT1 inhibition as a strategy to reverse toxicity. The toxicokinetics of this DDI were investigated, including brain-to-plasma concentration ratios, in the presence and absence of ethanol. The toxicodynamic parameters examined were respiratory depression (breathing frequency, tidal volume) and sedation (time of return-of-righting reflex). Ethanol was administered (2 g/kg i.v.) 5 minutes before the intravenous or oral administration of GHB, and MCT1 inhibitors AZD-3965 and AR-C155858 (5 mg/kg i.v.) were administered 60 minutes after GHB administration. Ethanol administration did not alter the toxicokinetics or respiratory depression caused by GHB after intravenous or oral administration; however, it significantly increased the sedation effect, measured by return-to-righting time. AZD-3965 or AR-C155858 significantly decreased the effects of the co-administration of GHB and ethanol on respiratory depression and sedation of this DDI and decreased brain concentrations and the brain-to-plasma concentration ratio of GHB. The results indicate that ethanol co-administered with GHB increases toxicity and that MCT1 inhibition is effective in reversing toxicity by inhibiting GHB brain uptake when given after GHB-ethanol administration. SIGNIFICANCE STATEMENT: These studies investigated the enhanced toxicity observed clinically when γ-hydroxybutyric acid (GHB) is co-ingested with alcohol and evaluated strategies to reverse this toxicity. The effects of the novel monocarboxylate transporter 1 (MCT1) inhibitors AR-C155858 and AZD-3965 on this drug-drug interaction have not been studied before, and these preclinical studies indicate that MCT1 inhibitors can decrease brain concentrations of GHB by inhibiting brain uptake, even when administered at times after GHB-ethanol. AZD-3965 represents a potential treatment strategy for GHB-ethanol overdoses.

Sex, drugs and techno - a qualitative study on finding the balance between risk, safety and pleasure among men who have sex with men engaging in recreational and sexualised drug use

BACKGROUND

Recreational and sexual drug use among men who have sex with men may result in increased risk of poor health. The aim of this study was to better understand drug use and harm reduction techniques among Swedish men who have sex with men traveling to Berlin in order to improve the health of this population and inform public health strategies.

METHODS

A qualitative study based on semi-structured interviews with 15 Swedish men aged 23-44 with experience of drug use were recruited through network sampling. Interviews were conducted in Stockholm and Berlin and analysed using content analysis. The interview guide included questions on drug use, context, health and safety.

RESULTS

The participants engaged in drug use in both settings and in various contexts. Participants saw themselves as capable of finding a balance between pleasure, safety and risk with the aim to maximize positive effects while minimizing negative ones. The different risks of drug use were known, and participants relied on knowledge, harm reduction strategies and self-defined rules of intake to stay safe and healthy in a broad sense, both short term (i.e. during each session) and long term. Choice of drug and, frequency of intake, multi-use, risk of overdose, risk of HIV, purpose and context of use, how often, etc. were all part of the overall strategy. Knowledge of these methods was spread within the community and on-line rather than from counsellors or other health care providers. However, it did not always translate perfectly into practice and some had experienced overdoses and problematic use.

CONCLUSIONS

The findings of this study point to the need for increased adoption of harm reduction techniques in this population focusing on mitigating harm and prevention of risk of problematic use or starting injection drugs. Existing traditional services require adaptations to become more accessible and acceptable to sub-groups of drug users, including low-threshold services providing non-judgemental, evidence-based information. This will require funding of alternative providers such as STI/HIV clinics, among others, and health care providers to increase adoption of prevention strategies, specifically pre-exposure prophylaxis for HIV.

Unity in diversity: A systematic review on the GHB using population

BACKGROUND

Over the past decades gamma-hydroxybutyrate (GHB) has emerged as a popular drug with high potential of (ab)use due to its euphoric and relaxing effects. An overview of different populations using GHB is urgently needed, since this would enable development of adequate prevention and treatment policies to diminish the risks associated with GHB use. We systematically reviewed literature on different GHB using populations, comparing demographic characteristics, GHB use patterns, psychosocial aspects and psychiatric comorbidity.

METHODS

We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using Rayyan software. Original studies published from January 1997 up to October 2019 on GHB use were included. Out of 80 full-text articles, 60 articles of 51 unique studies were included. Most studies included people using GHB 1) presenting at emergency departments (n = 22), 2) recruited from the general population (n = 11), or 3) presenting at addiction care (n = 8).

RESULTS

Three main sub-populations of people using GHB are described in the literature: people using GHB recreationally without adverse effects; people using GHB recreationally with adverse effects, and people with dependence on GHB. These groups show considerable overlap in gender, age range, and comorbid substance use, as well as amount of GHB use per occasion. Differences are related to frequency and function of GHB use, the number of comas experienced, as well as work status, and psychiatric comorbidity.

CONCLUSION

Policy interventions should aim at preventing the transition from recreational substance use to GHB use, as most users are experienced recreational substance users prior to starting GHB use. When people use GHB regularly, interventions should aim at reducing the level of GHB use and preventing GHB use-related harm. Longitudinal studies and population-based probability sampling are required for more insight in the dynamics of GHB use in different sub-populations, and the transition from one group to the other, ultimately leading to dependence on GHB.

[Chemsex : A new challenge in addiction medicine and infectious diseases]

BACKGROUND

Recently there has been an increase in reports of the phenomenon called chemsex, a subform of sexualized substance use. Chemsex is a neologism consisting of the two terms "chemicals" and "sex". It describes the use of methamphetamine, γ‑hydroxybutyrate/γ-butyrolactone (GHB/GBL), mephedrone and sometimes other substances in a sexual context, especially by men who have sex with men (MSM). Chemsex has been described as a significant risk factor for mental and physical diseases.

OBJECTIVE

Due to the increasing importance of the phenomenon and the significantly increased number of publications on the subject, this article provides an overview of the current and relevant literature. The aim is to raise awareness on this topic among practitioners and researchers and thus to facilitate access to the help system for those affected.

METHOD

A literature search was conducted in PubMed/Medline, Cochrane and Embase for the terms "chemsex", "sexualized drug use" and "slamming. A total of 22 articles were identified as being relevant.

RESULTS

In the published literature on chemsex the current focus lies on somatic comorbidities. There is a significantly increased risk of sexually transmitted diseases. Mental illnesses such as depression, substance-induced psychosis and addiction also appear to be a significant consequence of chemsex. An individualized and specialized treatment approach is not yet established.

DISCUSSION

The complexity of chemsex with its psychiatric and somatic aspects does not yet appear to be sufficiently reflected by the current data situation; however, due to the mutual influence of these different comorbidities, this patient clientele appears to be particularly at risk in the absence of a specialized treatment option, which is why further research on this topic is needed.

Association of Sexualized Drug Use Patterns with HIV/STI Transmission Risk in an Internet Sample of Men Who Have Sex with Men from Seven European Countries

We estimated the prevalence of overall sexualized drug use (SDU) and of chemsex in particular, assessed patterns of drug use, and identified subpopulations of men who have sex with men (MSM) where SDU and chemsex are more frequent. Using data from an online survey of 9407 MSM recruited during 2016 in 7 European countries, we calculated the proportion of participants who reported SDU and chemsex (mephedrone, methamphetamine, and/or GHB/GBL) in the last 12 months. We grouped the different drug-use combinations in patterns and described sexual risk behaviors, sexually transmitted infections (STI), and HIV seropositivity for each one of them. Factors associated with SDU and chemsex were assessed with two logistic regression models. SDU was reported by 17.7% and chemsex by 5.2%. Risk indicators increased through the different SDU patterns but were higher within those including chemsex drugs. In the multivariate analysis, chemsex was independently associated with living in Slovenia. Both SDU and chemsex were independently associated with living in Spain; being < 50 years old; living in cities of > 500,000 inhabitants; being open about their sex life; reporting transactional sex; condomless anal intercourse; having received an STI diagnosis and with being HIV positive or having been tested ≤ 12 months ago. Magnitude of associations was higher in the chemsex model. One in five participants reported SDU, but prevalence of chemsex was notably lower. However, the risk profiles and higher prevalence of HIV/STIs among those involved in chemsex suggest the existence of a subpopulation of MSM that could be playing a relevant role in the HIV and STI epidemics, especially in very large cities of some countries.

γ-Hydroxybutyric Acid: Pharmacokinetics, Pharmacodynamics, and Toxicology

Gamma-hydroxybutyrate (GHB) is a short-chain fatty acid present endogenously in the brain and used therapeutically for the treatment of narcolepsy, as sodium oxybate, and for alcohol abuse/withdrawal. GHB is better known however as a drug of abuse and is commonly referred to as the "date-rape drug"; current use in popular culture includes recreational "chemsex," due to its properties of euphoria, loss of inhibition, amnesia, and drowsiness. Due to the steep concentration-effect curve for GHB, overdoses occur commonly and symptoms include sedation, respiratory depression, coma, and death. GHB binds to both GHB and GABAB receptors in the brain, with pharmacological/toxicological effects mainly due to GABAB agonist effects. The pharmacokinetics of GHB are complex and include nonlinear absorption, metabolism, tissue uptake, and renal elimination processes. GHB is a substrate for monocarboxylate transporters, including both sodium-dependent transporters (SMCT1, 2; SLC5A8; SLC5A12) and proton-dependent transporters (MCT1-4; SLC16A1, 7, 8, and 3), which represent significant determinants of absorption, renal reabsorption, and brain and tissue uptake. This review will provide current information of the pharmacology, therapeutic effects, and pharmacokinetics/pharmacodynamics of GHB, as well as therapeutic strategies for the treatment of overdoses. Graphical abstract.

Complications Related to Sexualized Drug Use: What Can We Learn From Literature?

Chemsex is described as the use of specific psychoactive substances (PS) during sexual activity to sustain, enhance, disinhibit or facilitate the sexual experience. It preferentially concerns men who have sex with men (MSM). They use new synthetic substances like cathinones, methamphetamines, gamma-butyrolactone/gamma-hydroxybutyrate (GBL/GHB), ketamine, and cocaine. The prevalence of chemsex varies from 3 to 31% during lifetime. The Internet has participated significantly in the evolution of sexual behaviors, both in terms of sexual dating and the availability of new synthetic substances. The advent of geolocation applications contributed to the development of chemsex. The literature describes many complications linked to these sexual practices; the main clinical effects related to cathinones consumption were psychiatric symptoms; agitation, hallucinations, anxiety, suicidal ideation, paranoia, and confusion. Regular GBL/GHB consumption alter cognitive functions, particularly memory and emotion management. Use of these drugs in party and play is dramatically associated with high-risk sexual behaviors. The prevalence of hepatitis B, hepatitis C syphilis, and HIV is higher in men who use methamphetamine and Viagra and/or who declared they practiced slamming, chemsex, and fisting. Other sexually transmitted infections (STIs) such as gonorrhea have increased with methamphetamine and GHB/GBL use. Actually, the care of individuals who practice Chemsex in a problematic way is currently not codified, but the use of integrative and specific interventions is necessary.

Chemsex in Italy: Experiences of Men Who Have Sex With Men Consuming Illicit Drugs to Enhance and Prolong Their Sexual Activity

BACKGROUND

Chemsex is a novel phenomenon referring to the consumption of illicit drugs to facilitate, enhance, and prolong the sexual experience in men who have sex with men (MSM).

AIM

The present study aims to investigate contexts, patterns of substance use, first chemsex experience, and harm reduction in a group of MSM practicing chemsex in Italy.

METHODS

Thirty MSM involved in chemsex activities were interviewed between February and July 2019.

OUTCOMES

The interviews were conducted using an ad hoc grid exploring general characteristics of Italian chemsex, patterns of substance use, first chemsex experience, and harm reduction opinions.

RESULTS

Chemsex in Italy showed important peculiarities and patterns because of sociocultural background. Chemsex was mainly reported in private venues within couple and group sexual activities. Most participants attended chemsex sessions about 1-2 times per month often concurring with men-only club events. Freebase cocaine emerged among the most relevant substances consumed together with gamma-hydroxybutyrate/gamma-butyrolactone, crystal methamphetamine, and mephedrone. A rare use of injected substances compared with other European Union countries was shown. Given the high prevalence of erectile problems, a large use of phosphodiesterase type 5 inhibitors was reported, and noncoital sexual activities were usually preferred (eg, oral sex, fist fucking). The first chemsex experiences were usually accessed by geolocation-based dating apps and sexual partners and were generally described as positive experiences, with some negative consequences at the end of the session (dysphoric mental states, guilt, craving). Taking part in international gay events seems to favor the first experience of chemsex for some participants. Moreover, some MSM practiced chemsex only abroad or in other cities in Italy so as not to be recognized as chem users in their daily environment.

CLINICAL TRANSLATION

Implications for ad hoc harm reduction programs are discussed.

STRENGTHS & LIMITATIONS

Despite the methodological limitations due to participants' number and the absence of interviews audio recording, results highlighted some relevant characteristics of chemsex in Italy, such as freebase cocaine use, attitudes regarding slamming, geographical movements, and secrecy.

CONCLUSION

The results revealed a need for greater scientific and public attention on chemsex to act with the most specific and effective prevention and harm reduction tools. Nimbi FM, Rosati F, Esposito RM, et al. Chemsex in Italy: Experiences of Men Who Have Sex With Men Consuming Illicit Drugs to Enhance and Prolong Their Sexual Activity. J Sex Med 2020;17:1875-1884.

Changes in sexual behavior patterns due to stimulants use: three case reports

The paper describes three case reports of changes in sexual behavior patterns in male patients who use stimulants (amphetamine and mephedrone). Two of them demonstrate that the consumption of stimulants may lead to hypersexuality and excessive masturbation. Case report three shows that mephedrone use results in such typical stimulant-related subjective effects as the intensification of sensory experiences and sexual arousal. It leads to the loss of interest in sex without mephedrone. In light of the popularity of sex under the influence of drugs, clinicians should be aware of this phenomenon, since it is associated with high-risk sexual behavior. The description of clinical cases on the link between sex and drugs expands our knowledge in this area, leading to more effective treatment interventions.

Chemsex in Moscow: investigation of the phenomenon in a cohort of men who have sex with men hospitalized due to addictive disorders

The present study was designed to investigate the phenomenon of chemsex among Moscow men who have sex with men (MSM) patients who were hospitalized due to various addictive disorders. It was an observational cohort study which included a total of 30 male patients who underwent inpatient treatment at the Moscow Research and Practical Centre on Addictions of the Moscow Department of Healthcare due to various addictive disorders. Data on sociodemographic, sexuality-, sexually transmitted infection- (STI-), and drug use-related characteristics obtained in face-to-face interviews were recorded in all patients. Mean (SD) age of the patients was 24.3 (3.5) years. Mephedrone was the drug most commonly reported as being used for chemsex (over half of cases); it was consumed by 16 patients. Gamma-hydroxybutyric acid/gamma-butyrolactone use was reported by 6.7% of patients; 16.7% of patients preferred cocaine; ketamine use was present only in one patient. Five participants (16.7%) reported the use of other stimulants. Overall, 20% of patients reported their HIV serostatus as positive. Self-reported other STI status was positive in 12 patients (40.0%). Our findings revealed that practicing chemsex among MSM can be considered a trend in Moscow. Our study emphasizes the role of collaborative work of sexologists and addictologists in order to develop and evaluate the interventions.

Trends in gamma-hydroxybutyrate-related harms based on ambulance attendances from 2012 to 2018 in Victoria, Australia

BACKGROUND AND AIMS

Although the prevalence of gamma-hydroxybutyrate (GHB) use is relatively low globally, harms related to the drug appear to be increasing. Few existing studies present reliable, representative, population-level data on GHB-related harms. The aim of this study was to investigate trends in acute GHB-related harms within an ambulance database in Australia.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional, retrospective analysis of data on all GHB-related ambulance attendances in the state of Victoria, Australia during a 7-year period (January 2012-December 2018) MEASUREMENTS: Presentations were characterized based on patient demographics, transport to hospital, co-occurring substance use (i.e. GHB only, alcohol, methamphetamine, heroin, benzodiazepine and cannabis) and clinical presentation (e.g. symptoms of anxiety, psychosis, depression).

FINDINGS

There were 5866 GHB-related ambulance attendances between 2012 and 2018, with the prevalence rate increasing from 8.8 per 100 000 population in 2012 to a maximum of 21.7 per 100 000 population in 2017. Methamphetamine [odds ratio (OR) = 6.23, P < 0.001] and benzodiazepine-related (OR = 1.43, P < 0.001) co-occurrences; ages between 18-29 (OR = 6.58, P < 0.001) and 30-39 years (OR = 2.02, P < 0.001); and male gender (OR = 1.23, P < 0.001) were significant predictors of GHB-related attendances.

CONCLUSIONS

There has been a 147% increase in the prevalence of GHB-related ambulance attendances in Victoria, Australia between 2012 and 2019, largely attributable to a growth in the proportions of people using gamma-hydroxybutyrate alone or concurrently with methamphetamine.

Sharing solutions for a reasoned and evidence-based response: chemsex/party and play among gay and bisexual men

This Special Issue of Sexual Health examines research and healthcare practice relating to sexualised drug use among gay, bisexual and other men who have sex with men (GBMSM), colloquially known as 'chemsex' or 'party and play' (PnP). It draws together evidence relating to the epidemiology, sociology and psychology of chemsex, as well as the policy, community and clinical interventions that are required to ensure men have access to high-quality health care that meets their needs and reduces harm. Findings and discussions within the Issue emphasise the need to sensitively, non-judgementally and meaningfully engage with gay men about their engagement in chemsex in order to help improve their sexual health and wider wellbeing.

Intensive sex partying with gamma-hydroxybutyrate: factors associated with using gamma-hydroxybutyrate for chemsex among Australian gay and bisexual men - results from the Flux Study

Background Gamma-hydroxybutyrate (GHB) use among gay and bisexual men (GBM) has increased in recent years. It is commonly cited as a sexual-enhancement drug. There is, however, little evidence for factors associated with GHB use or the consequences of its use among GBM.

AIM

Factors associated with GHB use, its relationship to sexual risk behaviour, and the contexts, consequences, and motivations for its use were examined.

METHODS

The Following Lives Undergoing Change (Flux) Study is an online prospective observational study of Australian GBM. At baseline, a total of 3190 GBM provided details about their use of GHB. Data on frequency, methods, pleasures and consequences of their drug use, alongside key demographic variables were collected.

RESULTS

Mean age was 35.0 years. One in five men (19.5%) had a history of GHB use and 5.4% reported use within the past 6 months, with 2.7% having used it monthly or more frequently. Overdose had been experienced by 14.7%, this was more common among men who used GHB at least monthly. Being HIV-positive, having more gay friends, greater social engagement with gay men who use drugs, a greater number of sexual partners, group sex, and condomless anal intercourse with casual partners were independently associated with GHB use in the past 6 months. Greater social engagement with gay men who use drugs and group sex were independently associated with at least monthly use. More frequent GHB use was independently associated with experiencing overdose among GHB users.

CONCLUSION

Most men used GHB infrequently and it was often used explicitly to enhance sexual experiences, often in the context of intensive sex partying. Men who used GHB frequently, were at greater risk of overdose and other negative health outcomes. GHB use should be considered alongside other drugs that have been implicated in sexual risk behaviour and HIV transmission. Harm-reduction interventions need to consider the particular impact of frequent GHB use.

Low levels of chemsex among men who have sex with men, but high levels of risk among men who engage in chemsex: analysis of a cross-sectional online survey across four countries

Background This paper establishes the prevalence of chemsex drug use among men who have sex with men (MSM), the extent to which these drugs are used in a sexual context, as well as their associated behaviours and circumstances of use.

METHODS

Data from a cross-sectional, online survey of 2328 MSM recruited via gay sociosexual media in Scotland, Wales, Northern Ireland and the Republic of Ireland were analysed.

RESULTS

While almost half (48.8%) of participants had ever taken illicit drugs, lifetime chemsex drug use was less common (18.0%) and far fewer reported chemsex drug use in the last year (8.2%) or last 4 weeks (3.0%). Just over one-quarter (27.1%) of men who used chemsex drugs in the last year reported no sexualised drug use, but almost three-quarters (72.9%) did. Only 6.1% of the whole sample reported sexualised chemsex drug use in the last year. The odds of reporting chemsex in the last year were significantly higher for men aged 36-45 years (AOR=1.96), single men (AOR=1.83), men who were HIV positive (AOR=4.01), men who report high-risk sex (AOR=4.46), being fisted (AOR=7.77) or had sex in exchange for goods other than money (AOR=4.7) in the last year and men who reported an HIV test in the last 3 months (AOR=1.53).

DISCUSSION

Only a small proportion of MSM in Scotland, Wales, Northern Ireland and the Republic of Ireland reported chemsex, and, for the first time, it is demonstrated that not all chemsex drug use was sexualised. Nevertheless, MSM who engage in chemsex (MWEC) reported substantial sexual risk inequalities. These novel findings highlight several opportunities for intervention, particularly around the multiple vulnerabilities of MWEC, opportunities for early identification of those most vulnerable to chemsex-related harm and the potential to develop a specialised responsive patient pathway.

Clinical relevance of ethanol coingestion in patients with GHB/GBL intoxication

OBJECTIVE

Ethanol intake can increase the sedative effects of gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), although the real clinical impact is unknown. We studied the clinical impact of the co-ingestion of ethanol in patients presenting to the Emergency Department (ED) with acute toxicity related to GHB/GBL use.

METHOD

We performed a secondary analysis of the Euro-DEN Plus Registry (14 countries, 22 EDs) which includes 17,371 consecutive patients presenting to the ED with acute recreational drug toxicity over 39 consecutive months (October 2013 - December 2016). We compared the epidemiological and clinical characteristics and ED management of patients identified as presenting with acute toxicity related to lone GHB/GBL (Group A) or GHB/GBL combined with ethanol (Group B) without other concomitant drugs.

RESULTS

A total of 609 patients were included (age 32 (8) years; 116 women (19%); Group A: 183 patients and Group B: 426). The most common features were reduction in consciousness (defined as Glasgow Coma Score <13 points: 56.1%) and agitation/aggressiveness (33.6%). Those with ethanol co-ingestion were younger patients (Group A/B: 31.5/33.1 years, p = 0.029) and ethanol co-ingestion was associated with a lower frequency of bradycardia (23.5%/15.7%, p = 0.027) and more frequent arrival at the ED by ambulance (68.3/86.6%; p < 0.001), reduction in consciousness (58.9%/49.1%; p = 0.031), need for treatment in the ED (49.2%/60.4%; p = 0.011), use of sedatives (20.1%/12.8%; p = 0.034), admission to critical care units (22.4%/55.3%; p < 0.001), and longer hospital stay (stay longer than 6 h: 16.9%/28.4%; p = 0.003).

CONCLUSIONS

Co-ingestion of ethanol increases the adverse effects of patients intoxicated by GHB/GBL, leading to greater depression of consciousness, need for treatment, admission to the ICU and longer hospital stay.

Latent classes of sexual risk and corresponding STI and HIV positivity among MSM attending centres for sexual health in the Netherlands

OBJECTIVES

Continuing high STI positivity among men who have sex with men (MSM) attending centres for sexual health (CSH) indicates that high-risk behaviour is ongoing. The objective of this study was to gain a better insight into risk behaviours among MSM attending CSH and to explore STI and HIV positivity by subgroups.

METHODS

We used national data routinely collected during CSH consultations for this study. From September to December 2017, questions on group sex, substance use and sex with HIV-positive partners were asked at each CSH consultation. We analysed latent classes of client-related factors and sexual risk behaviour among MSM attending CSH in this period. We examined STI positivity and prevalence ratios by latent classes.

RESULTS

A total of six classes were identified in order of increasing risk: 'overall low-risk behaviour' (n=2974; 22.0%), 'Western origin and multiple sex partners' (MSP) (n=4182; 30.9%), 'Non-Western origin and MSP' (n=2496; 18.5%), 'living with HIV' (n=827; 6.1%), 'group sex and HIV-positive partners' (n=1798; 13.3%) and 'group sex and chemsex' (n=1239; 9.2%). The any STI positivity ranged from 14.0% in the overall low-risk behaviour class to 35.5% in the group sex and chemsex class. HIV positivity did not differ significantly between classes. The Western origin and MSP class was largest and accounted for the majority of STI and HIV infections.

CONCLUSIONS

Although STI positivity increased with increased risky behaviours, considerable STI positivity was found in all six latent classes. Comparable HIV positivity between classes indicates risk reduction strategies among subgroups engaged in risky behaviours. The differences in risk behaviour and STI positivity require preventive strategies tailored to each subgroup.

Recreational drugs and STI diagnoses among patients attending an STI/HIV reference clinic in Rome, Italy

BACKGROUND

An observational study was conducted to assess recreational drug use in association with recent STIs among clients of an STI/HIV reference centre in Rome, Italy.

METHODS

Attendees self-compiled a questionnaire concerning sexual behaviours and drug use, including the nine drugs used for sex (amphetamines, poppers, cocaine, ketamine, erectile dysfunction agent (EDA), steroids and the three chemsex drugs, ie, chems: γ-hydroxybutyric acid/γ-butyrolactone, crystal and Mcat).

RESULTS

Overall, 703 patients participated, with men who have sex with men (MSM) accounting for 50.4% of the total and 73.2% of HIV-positive patients. Apart from condylomatosis, whose prevalence was higher among females (38.8%) and non-MSM (45.8%) than MSM (14.4%), STIs were more frequent among MSM, particularly syphilis (14.1%), gonorrhoea (4.8%), urethritis (3.4%) and hepatitis A (6.5%). Recreational drug use was significantly more frequent among MSM (39.8% vs 17.6% in females and 22.7% in non-MSM). A total of 26.3% of MSM used at least one of the nine drugs and 5.1% at least one of the three chems. Cocaine (13.3%) and poppers (13.0%) were the most used sex drugs in MSM.The use of any of the nine drugs was associated with being MSM (adjusted OR (AOR): 1.94, 95% CI 1.05 to 3.58), sex with partner contacted online (1.99, 95% CI 1.14 to 3.45), group sex (4.08, 95% CI 2.40 to 6.93) and STI in the last year (1.65, 95% CI 1.05 to 2.61). Use of any of the nine chems among MSM was associated with condomless sex (2.24, 95% CI 1.21 to 4.14), group sex (2.08, 95% CI 1.01 to 4.31) and STI diagnosis in the last year (4.08, 95% CI 2.32 to 7.19).

CONCLUSIONS

Our data suggest that recreational drug use is quite common among MSM in Italy. No evidence of association with STI was found among non-MSM and females, where only cannabis and cocaine use was reported. The use of chems is still limited, but cocaine, poppers and EDA are widely used among MSM. Recreational drug use appears associated with high-risk sexual behaviours and a higher risk of STI.

Intimate partner violence, depression, and sexual behaviour among gay, bisexual and other men who have sex with men in the PROUD trial

Background

Little is known about the prevalence and correlates of intimate partner violence (IPV) among gay, bisexual and other men who have sex with men (GBMSM) in the UK. The aim of this study was to investigate the prevalence of IPV, associations of socio-economic and psychosocial factors with IPV, and the association of IPV with depression and sexual behaviour, among GBMSM in the PROUD trial of pre-exposure prophylaxis (PrEP).

Methods

PROUD enrolled 544 HIV-negative participants in England from 2012 to 2014; participants were randomised to immediate or deferred PrEP. This analysis included 436 GBMSM who had IPV data at month-12 and/or 24. Prevalence of IPV victimization and perpetration (lifetime, and in the past year) was assessed at these time-points. Generalized estimating equations were used to investigate associations with IPV, using pooled data from both time-points.

Results

At month-12 (N = 410), 44.9% of men reported ever being a victim of IPV, 15.6% in the last year, and 19.5% reported ever perpetrating IPV, 7.8% in the last year. At month-24 (N = 333), the corresponding prevalence was 40.2 and 14.7% for lifetime and past year IPV victimization and 18.0 and 6.9% for lifetime and past year IPV perpetration. IPV prevalence did not differ by randomised arm. Men reporting internalized homophobia and sexualized drug use were more likely to report IPV. Lifetime and last year experience of IPV victimization and perpetration were strongly associated with depressive symptoms (PHQ-9 ≥ 10) (adjusted for socio-demographics: lifetime IPV victimization PR 2.57 [95% CI: 1.71, 3.86]; past year IPV victimization PR 2.93 [95% CI: 1.96, 4.40]; lifetime IPV perpetration PR 2.87 [95% CI: 1.91, 4.32]; past year IPV perpetration PR 3.47 [95% CI: 2.13, 5.64], p < 0.001 for all); IPV was not consistently associated with measures of condomless anal sex or high partner numbers.

Conclusions

GBMSM at high-risk of HIV who are seeking/taking PrEP may experience a high burden of IPV, which may be linked to depression. Training on awareness of and enquiry for IPV among GBMSM in sexual health clinics is recommended.

Trial registration

ClinicalTrials.gov identifier: NCT02065986. Registered 19 February 2014 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6757-6) contains supplementary material, which is available to authorized users.

Treatment of γ-Hydroxybutyric Acid and γ-Butyrolactone Overdose with Two Potent Monocarboxylate Transporter 1 Inhibitors, AZD3965 and AR-C155858

The illicit use of γ-hydroxybutyric acid (GHB), and its prodrug, γ-butyrolactone (GBL), results in severe adverse effects including sedation, coma, respiratory depression, and death. Current treatment of GHB/GBL overdose is limited to supportive care. Recent reports indicate that GHB-related deaths are on the rise; a specific treatment may reduce lethality associated with GHB/GBL. Pretreatment with inhibitors of monocarboxylate transporter 1 (MCT1), a transporter that mediates many of the processes involved in the absorption, distribution (including brain uptake), and elimination of GHB/GBL, has been shown to prevent GHB-induced respiratory depression by increasing the renal clearance of GHB. To identify whether MCT1 inhibition is an effective treatment of GHB overdose, the impact of two MCT1 inhibitors, (S)-5-(4-hydroxy-4-methylisoxazolidine-2-carbonyl)-1-isopropyl-3-methyl-6-((3-methyl-5-(trifluoromethyl)-1H-pyrazol-4-yl)methyl)thieno[2,3-day]pyrimidine-2,4(1H,3H)-dione (AZD3965) and 6-[(3,5-dimethyl-1H-pyrazol-4-yl)methyl]-5-[[(4S)-4-hydroxy-2-isoxazolidinyl]carbonyl]-3-methyl-1-(2-methylpropyl)thieno[2,3-day]pyrimidine2,4(1H,3H)-dione (AR-C155858), on the toxicokinetics and toxicodynamics of GHB/GBL was assessed when the administration of the inhibitor was delayed 60 and 120 minutes (post-treatment) after administration of GHB/GBL. AR-C155858 and AZD3965 reduced the toxicodynamic effects of GHB when GHB was administered intravenously, orally, or orally as the prodrug GBL. The impact of these inhibitors on GHB toxicokinetics was dependent on the route of GHB administration and the delay between GHB/GBL administration and administration of the MCT1 inhibitor. The reduction in GHB plasma exposure did not explain the observed effect of MCT1 inhibition on GHB-induced respiratory depression. The efficacy of MCT1 inhibition on GHB toxicodynamics is likely driven by the pronounced reduction in GHB brain concentrations. Overall, this study indicates that inhibition of MCT1 is an effective treatment of GHB/GBL overdose.

Sexual orientation and sex-related substance use: The unexplored role of bisexuality

Using alcohol and drugs in sexual contexts is associated with negative health consequences, including increased risk for HIV/STIs, sexual victimization, unplanned pregnancies, and overdose. Evidence suggests millions of adults regularly use alcohol in sexual contexts, thus increasing their risk for these consequences. However, no nationally representative estimates exist for rates of regular alcohol and/or drug use in sexual contexts. Additionally, previous studies suggest sexual minority individuals are more likely to use substances in sexual contexts than heterosexuals; however, none of these studies examined for multiple dimensions or subgroups of sexual orientation. Thus, using two distinct datasets-one large, nationally representative sample (N = 17,491) and an Internet-collected convenience sample (N = 1001)-we explored the associations between sexual orientation (dimensions and subgroups) and rates of regular sex-related alcohol and/or drug use in American adults. Results showed that sexual minority individuals were significantly more likely to report regularly using substances in sexual contexts compared to heterosexuals; however, results varied based on dimension of sexual orientation and by sex. Across both samples, bisexual individuals exhibited the highest rates of regular sex-related substance use. Findings suggest that sexual minorities, and bisexual individuals in particular, may be at increased risk for regular sex-related substance use and its associated negative health consequences. Future research should include nuanced and multidimensional assessments of sexual orientation to investigate sex-related alcohol and/or drug use and its associated risks, as well as examine the potential direct and indirect pathways by which these disparities may be conferred.

The problematic chemsex journey: a resource for prevention and harm reduction

Purpose

Chemsex is a phenomenon that has gained increasing attention in recent years. The purpose of this paper is to differentiate chemsex from other sexualized substance use, and clarify differences between recreational and problematic chemsex use. Despite plentiful publications, little has been published on underlying determinants that predispose individuals to chemsex, and their process toward problematic chemsex use.

Design/methodology/approach

During the second European Chemsex Forum, people who engage in chemsex, community organizers, researchers, clinicians, therapists, social workers and (peer) counselors discussed potential pathways to problematic chemsex. In this manuscript, we translate findings from these discussions into a framework to understand the initiation and process toward problematic chemsex.

Findings

Six stages (loneliness and emptiness, search for connection, sexual connection, chemsex connection, problematic chemsex and severe health impact) and a set of factors facilitating the transition from one stage to the next have been identified.

Originality/value

It is hoped that this “Journey towards problematic chemsex use” will stimulate reflection and debate, with the ultimate goal of improving prevention and care for people engaging in chemsex.

Chemsex and new HIV diagnosis in gay, bisexual and other men who have sex with men attending sexual health clinics

OBJECTIVES

The aim of the study was to analyse associations between chemsex and new HIV and sexually transmitted infection (STI) diagnoses among gay, bisexual and other men who have sex with men (GBMSM) accessing sexual health clinics.

METHODS

A retrospective case note review was carried out for all GBMSM attending two London sexual health clinics between 1 June 2014 and 31 July 2015.

RESULTS

Chemsex status was documented for 1734 of 1840 patients. Overall, 27.1% (n = 463) disclosed current recreational drug use, of whom 286 (16.5%) disclosed chemsex participation and 74 of 409 (18.1%) injected drugs. GBMSM who were already HIV positive were more likely to disclose chemsex participation [adjusted odds ratio (AOR) 2.55; 95% confidence interval (CI) 1.89-3.44; P < 0.001]. Those disclosing chemsex participation had higher odds of being newly diagnosed with HIV infection (AOR 5.06; 95% CI 2.56-10.02; P < 0.001), acute bacterial STIs (AOR 3.94; 95% CI 3.00-5.17; P < 0.001), rectal STIs (AOR 4.45; 95% CI 3.37-6.06; P < 0.001) and hepatitis C (AOR 9.16; 95% CI 2.31-36.27; P = 0.002). HIV-negative chemsex participants were also more likely to have accessed post-exposure prophylaxis for HIV in the study period and to report sex with a discordant HIV- or hepatitis C virus-infected partner (P < 0.001).

CONCLUSIONS

Chemsex disclosure in sexual health settings is associated with higher rates of STI diagnoses, including HIV infection and hepatitis C. GBMSM attending sexual health services should therefore be assessed for chemsex participation and disclosure should prompt health promotion, harm minimization and wellbeing interventions.