Learn how drugs work in the body!

1. Drugs & Body Workshop TRIP! Outreach Training Spring 2011 Nick Boyce: nboyce@ohsutp.ca Wende Wood: wendewood@hotmail.com

2. Before we start… All of us have different experiences and insights. Back to basics. Questions as we go. For some stuff, you will know more than us. If we’re not sure about something we can look it up later. What we know changes. New issues; new science. Do your homework!

3. Introductions Group Guidelines Safe Space & Confidentiality “I” statements Step up / Step back Cell phones Who you are Name; how long you have been “partying”; when you heard of/got involved with TRIP! Something you are hoping to take away from the training Specific drug(s) you want to find out/know more about? Can you think of a situation with yourself or a friend that presented a problem (e.g., bad trip; OD; wrong drugs; etc.)

4. Workshop Overview Drug: Set : Setting Things to think about Body & Brain: Effects of drugs on body Effects of body on drugs Neuro-Physiology Interactions Ways drugs are taken: How drugs get into the body Risks and benefits Where are people at? The continuum of use

5. Workshop Overview What are people saying? TRIP! Survey Data Specific substances: What they are How they work Immediate risks Longer-term concerns Risk reduction strategies Resources & Referrals

6. What are some…? Drugs…? Prescriptions…? Medications…?

8. Herbal medications from health food stores

9. Birth control pills

10. Over-the-counter cold remedies

11. Tylenol

12. Beer

13. Prescribed medicines

15. Drug : Set : Setting Three interrelated factors affecting a person’s experiences and risks: Drug The drug, medication, pill being consumed. Set The person taking the substance. Setting The context in which it is taken.

16. DrugWhat substance(s)? The specific pharmacology of the substance(s) Effects on physiology and neurochemistry. Half-life: How long does it take the body to eliminate it? How much is taken Potency. For some drugs you can take tiny amounts, others require a lot. How it is taken (route of administration) affects: How quickly the feeling “comes on”. How intense it feels. How long it lasts. Quality of illicit substances It may be hard to know what you’re getting; the ingredients can include anything. What are they cut with? A dealer may say a substance is one thing but sell something else. It may look like the stuff from last time but it might be stronger or weaker, or have different ingredients.

17. Classes of Substances(primarily illicit substances listed)

18. Prescription Medications Opioids include pain medications with active ingredients such as morphine, oxycodone and codeine. Tylenol 3s; Percocets; Oxycontin Tranquillizers are often prescribed to reduce stress and panic attacks. benzodiazepines such as diazepam (Valium®) and alprazolam (Xanax) Stimulants are often used to treat ADD/ADHD. dextroamphetamine (Adderall); methylphenidate (Ritalin)

19. Prescription Medications Antidepressant are used to alleviate mood disorders, such as major depression and dysthymia. selective serotonin reuptake inhibitors (SSRIs: Celexa; Zoloft; Prozac); serotonin-norepinephrine reuptake inhibitors (SNRIs: Effexor); monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs)… Barbiturates treat anxiety, sleep disorders and seizures pentobarbital sodium (Nembutal) and mephobarbital (Mebaral). Anitpsychotics are primarily used to manage psychosis particularly in schizophrenia and bipolar disorder: haloperidol (Haldol) olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and aripiprazole (Abilify)

20. SetWho’s taking the substance? Size and body weight. Physical, mental, psychological state. How tired they are. Their mood before they use. Their reason(s) for using. Genetics. How does their body metabolize drugs? Experiences with this or other substances. Tolerance; Habituation; Sensitization Expectation, or anticipation, of how the substance will feel or effect them. Did they eat recently if swallowing a drug? Are they using other substances at the same time?

21. SettingWhat’s the context? Where are they? Alone; with friends; with strangers? Indoors or outdoors? Quite setting or lots of people and noise? What time of day? What type of music is playing? Rules and regulations. Community and social attitudes towards certain substances or ways or taking them. The legal status of different substances.

22. Drugs and Body Classes of drugs Stimulants CNS Depressants Opioids Sedatives/Hypnotics Hallucinogens Dissociative Anaesthetics Entactogens Effects of drugs on body Effects of body on drugs

23. Drugs on Body Effects of drugs on body What is the high like? What receptors does it attach to? What physiological effects will it have? What psycho-behavioural effects will it have? What interactions will it have with other drugs and medications? (common receptors) What happens if you OD? Why do we get high anyway? Neurotransmitters Receptors Reuptake Pumps

24. Body on Drugs Effects of body on drugs Getting drugs in Routes of administration Getting drugs around Getting drugs out How long do they last? Half life Interactions with other drugs and medications? (metabolism) Adaptation; tolerance; withdrawal

25. Body Physiology Key organs and processes of the body Heart Kidneys Liver Brain Temperature Blood pressure Heart rate

26. Brain Physiology What does it do Major regions Neurotransmitters Neuroreceptors Reuptake Pumps

27. Neurotransmitters Amines Serotonin Dopamine Norepinephrine Epinephrine Acetylcholine Tyramine Octopamine Phenylethylamine Tryptamine Melatonin Histamine Pituitary Peptides Circulating Hormones Hypothalamic Releasing Hormones

28. Neural Pathways

29. Brain Physiology 101 Neurons: brain signals and messages axon dendrite

30. Brain Physiology 101 Synapse: site of communication

31. Brain Physiology 101 Synapse: normal communication

32. Brain Physiology 101 Synapse: under the influence

33. Brain Physiology 101 Synapse: after the influence - reuptake

34. Brain Physiology 101 Synapse: site of communication

35. Brain Physiology 101 Synapse: normal communication

36. Brain Physiology 101 Synapse: under the influence

37. OVERDOSE RISK DEPRESSANTS CNS Depression, respiratory depression, coma Highest risk with opioids (heroin, oxycontin), barbiturates, alcohol, GHB Benzodiazepines in high doses especially combined with alcohol &/or other depressants STIMULANTS unpredictable dehydration, overheating, cardiovascular problems, seizure paranoia, agitation, hallucinations HALLUCINOGENS Not much direct risk from overdose per se, however psychiatric effects can lead to dangerous situations (i.e. a “bad trip”), or trigger underlying disorder

38. Interactions When two or more substances are taken at or near the same time an interaction may occur This may create new effects that are different than those from either drug taken alone They may: Act independently of each other Enhance each other's effects Potentiation: multiplying the effects of two drugs rather than simply doubling the dose Have an antagonistic effect some drugs block the effects of other

39. Drug interactions may occur when combining recreational drugs with: Other recreational drugs Prescribed psychotropic medications Other prescribed drugs (including medications prescribed for medical conditions) Over-the-counter medications Herbal and natural products Alcohol Tobacco

40. Anticipating Interactions - Challenges Drug potency, strength, dose Drug purity – contaminants, adulterants Research studies lacking, inconclusive, unethical Drug interaction information based on unproven theories or case reports with incomplete data Person not forthcoming or doesn’t know all that they have taken Over-the-counter drugs, herbal products and grapefruit juice not often reported

41. Anticipating Interactions…. DEPRESSANTS 2 bottles Oxycontin 12 Vicodin (hydrocodone + acetaminophen) 2 bottles of Nyquil (doxylamine, pseudoephedrine, acetaminophen, DM) 18 chlorpheniramine antihistamines 10sleeping pills (benzodiazepines?) Vodka STIMULANTS 6 Ritalin (methylphenidate) 20 clenbuterol (beta-2-agonist used as diet pill) 18 herbal uppers (ephedra?) energy drink (caffeine?) GI MEDS 8 antacid reflux tabs 1 bottle of stomach upset mixture PeptoBismol 10 Zantac (ranitidine) tablets

42. Dave Started his night at friend’s drinking vodka cranberry. Before they left for the party he did a couple lines of blow. At the party he dropped a pill, did some shots and drank a Vodka Redbull. Later, he took a cap of MDMA and did some bumps of K. Becoming nauseous, he left the party and went to a friend’s to chill. Feeling better, he crushed some speed and they each did a rail before heading home to crash. He couldn’t find any G, so said he might knock himself out with some Ativan, or a couple of Gravols and a joint.

43. John Has been partying nearly every weekend for over a year, since moving to Toronto from a small town. His partying usually involves late nights including some drinking, 1-2 ecstasy pills each weekend, and some K once or twice a month when sketching at home. He has maintained a job in retail, has been going to the gym 3 times a week and seeing his friends on weekdays to hangout and have dinners. For the three months he has been trying to quit smoking and has been taking Zyban on and off. Six weeks ago he went to his doctor and said he was feeling down; he was prescribed him Celexa. For the last two weeks he has missed several days of work, has not gone to the gym and has only seen his friends out clubbing.

44. Kate Does not like to drink but smokes weed occasionally. She had never done any party drugs but recently she was introduced to Ketamine and enjoys snorting it at home with a couple of friends. She likes the feeling and enjoys K-holing. Last week, after people left her place, she found a baggie of powder on the coffee table. Assuming it was K she snorted a big line and hoped to K-out. Instead she felt a rush of energy and was very anxious for about an hour.

47. Sublingual (under the tongue)

48. Transdermal (through the skin)

49. Swallowing / Ingesting

51. Damage to lungs and airways.

54. Abscesses.

55. Easier to overdose.

61. Experimental Use - the person tries a substance and may or may not use it again.

62. Social or Occasional Use - the person uses the substance in an amount or frequency that is not harmful (e.g., drinks on a social occasion; ceremonial use).

63. Medication (prescribed) - the person uses a medication as directed, under medical supervision. Risks are minimized.

64. Problematic Use - the person experiences negative consequences from using a substance (e.g., health, family, school, work, financial, legal problems).

66. Some people may stay social users for their entire lives.

67. Some people can move around the continuum over time.

68. People can be at different points of the continuum for different substances.

69. Where a person is on the continuum, does not necessarily impact her/his ability to manage and minimize risks. For example:

70. Someone that is “heavily addicted” may still use new equipment every time.

71. A long time cocaine user may overdose.

72. A social user may overdoes or spend too much.

73. For people struggling with dependency, not using for a while, then using again (sometimes referred to as “relapse”) is the norm.

75. Signs of “Problematic Use” Some risks are acute; others are chronic Psychological / physical dependency CAGE Have you ever felt you should cut down on your use? Have people annoyed you by criticizing your use? Have you ever felt bad or guilty about your use? Have you ever used first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? Physical / mental health, spiritual, emotional, financial, social, driving, legal consequences…

76. 5 Risk Reduction Tips Self-directed harm reduction strategies to help avoid overdosing, bad highs, missing work, dehydration, or other consequences after use: Rationing Rules for selecting and mixing Controlling quality Maintaining a healthy lifestyle Following guidelines during use Adapted from: “Greenspan, N.R., et al. “It’s not rocket science, what I do”: Self-directed harm reduction strategies among drug using ethno-racially diverse gay and bisexual men. International Journal of Drug Policy (2010), doi:10.1016/j.drugpo.2010.09.004”

77. Rationing Limiting or regulating the quantity and/or frequency of use in a particular setting, or over a given time period. “I limit myself to two pills a night.” “I don’t party every weekend.” “I need time to recover before work on Monday.”

78. Rules for selecting and mixing Which drugs you will use. Certain characteristics maybe reasons to choose or avoid specific drugs: “It doesn’t leave me hung-over.”; “I can afford it.” “I won’t do that because it’s illegal.”; “I don’t like speedy drugs.” How you will take them. Method of consumption can be a deterrent: “I would never stick anything up my nose.” Which drugs you can use at the same time. Physical harms are often reason to avoid specific drugs or combinations: “If I mix these two I could pass out.” “This drug won’t mix well with my prescription.”

79. Controlling quality To ensure, as best you can, the quality of drugs used. Obtaining drugs from a “reliable source” Get to know your dealer Using drugs that have been (safely) used by others Ask around: “Peer Reviews” Trial & error and inspection Get to know how drugs look, taste, smell Become familiar with how they feel in the body and how long the effects last

80. Maintaining a healthy lifestyle Eating, resting, sleeping Drinking water Not sharing water bottles Taking vitamins and other supplements

81. Following guidelines during use Drinking water when partying Especially in hot environments or when physically exerting yourself Using with people you trust and have experience They can help if you have a problem Not sharing drug use equipment To avoid HIV and Hep C but even common cough and cold viruses Watch out for your drinks To prevent deliberate or accidental contamination

82. Rave Drugs / Club Drugs 1970’s - 1980’s: New York and Chicago discos Ibiza, Spain (UK Tourists) 1980’s - 1990’s: Underground Raves (U.K.); Warehouse Parties (New York, Chicago, Detroit, Toronto); Gay Nightclubs 1990’s - 2000’s: Nightclubs (U.K.) Raves, Nightclubs, Gay Circuit Parties (North America) 2000’s: Nightclubs; Gay Clubs; all-ages-all-night events “Parties”

83. “Party Drugs” A generalized term for substances that have historically been associated with raves and all night dance-clubs. These drugs are used by many kinds of people in all kinds of settings. Some of these drugs are illegal, some have no classification Examples: Ecstasy, Ketamine, GHB, Acid, Cocaine, Crystal Methamphetamine Newer Classes and Research Chemicals

84. “Party-Drugs”

86. TRIP! survey data 2008

87. Trends Of greatest concern was the re-emergence of crystal meth use over the past year. In 2007, only 15% of respondents identified using this substance in the last year or month. In 2008, the number rose to 26%. Also of concern was the number of people using prescription medication for psychoactive purposes. This question was not asked in the previous survey and has not been a focus for TRIP! in the past, but with more than 20 percent of people using these substances, more work needs to be done to address this in the coming year. Other than Oxycodone and Codeine, respondents identified using Adderal, Ritalin, Dexedrine, Diluadid, Concerta, Valium and Morphine.

88. Trends Small numbers of people indicated use of research chemicals such as DOB, DOI, DOC, 2CE, 2CC, 2CB, 2CI, 5-MeO-MiPT, and AMT, nitrous oxide, poppers, pcp, hasish, over the counter disassociative DXM, a variety of plant based hallucinogenics such as Kratom, Salvia, DMT, morning glory seeds, Mugwort T. Peruvianus (a cactus), and other amphetamines such as TMA, BZP, and MDA.

89. Drugs to talk about… Alcohol Amphetamine-type substances MDMA; Ecstasy Pills; Speed; Meth; Dexedrine; Ritalin Hallucinogens Phenylethamines; LSD; Mushrooms; Ketamine Benzos Atavan; Xanax; Clonazepam Opiates Oxies; percs; T3s Marijuana GHB Cocaine

90. Alcohol Neurotransmitters: GABA (inhibits brain activity) Alcohol stimulates GABA receptors, making them more inhibitory and further inhibiting brain activity Glutamate (brain’s general purpose excitatory transmitter) Binds to glutamate receptors preventing glutamate from exciting the cell Alcohol particularly effects areas involved in memory formation, decision making and impulse control

91. Alcohol Risk Reduction Alcohol does not mix well with many substances. Be cautious, and better to avoid, the following: Alcohol + Benzos Alcohol + Ketamine Alcohol + Opiates Alcohol + GHB This can be a particularly dangerous combination

92. Alcohol Risk Reduction Eat something before drinking Pace yourself Hydrate as you drink Prearrange transportation; leave car keys behind Take only the money you intend to spend Make your own drinks Only accept drinks from people you trust Monitor how often you’re drinking; take breaks “Liquor before beer, you’re in the clear; beer before liquor, never been sicker” (Nearly all liquor is quality and potency assured)

93. Non-palatable alcohol • Initiate a non-judgmental, factual discussion about the harms of using these substances. • Encourage the use of safer alcohols – beer, wine and liquor. • Discuss the use of less harmful, non-palatable alcohols (e.g., mouthwash rather than hand sanitizer). • Discuss options to reduce the amount of non-palatable alcohol consumed, and other strategies to reduce the potential for harm,

94. Ecstasy E, X, pills, disco biscuits Specific pills named based on colour, size, shape, stamp/logo Can come as powder in a gel cap $5-$20 a pill (Toronto 2009) Predominately swallowed Pills may be crushed in to powder and snorted Rarely hooped or smoked

95. Ecstasy Main neurotransmitter: Serotonin Though with adulterated pills others maybe effected (e.g., more dopamine if methamphetamine is in pills) Primarily stimulant effects; “upper” Though overwhelming sense of “bliss” may leave you feeling lethargic Physical effects: Increases in heart rate, body temperature and energy Jaw clenching/tightening, dilated pupils, nausea Psycho/behavioural effects: +ve: empathy, openness, peace, caring, open-hearted communication –ve: anxiety, paranoia, “bad mood”

96. Ecstasy Immediate risks: Not knowing what you get Ecstasy pills are one of the most adulterated illicit substances Dehydration; overheating; stroke Particularly when used in hot nightclubs and parties Say or do something you regret Tendency to talk openly and “feel connected” may not last the next day Rough comedown Can be hard to fall asleep You may feel sad, blue, and easily irritated for a couple of days after

97. Ecstasy Longer-term concerns: Tolerance Many longer-term users report taking more to get a similar effect (e.g., “½ a pill used to get me high, now I take 2 in a night”). Psychological Dependency If you have always taken ecstasy when going out dancing, it may be hard to not think about using when going out, even though your body isn’t physically needing it. Depression What goes up, must come down. Serotonin, one of the neurotransmitters ecstasy effects, is part of your eat/sleep patterns and mood cycles - it may be depleted after use. Anxiety & panic attacks Stimulant drugs can create a sense of urgency or paranoia in some people, especially with the more you take or the longer you stay high.

99. Ecstasy Pills The Pink Heart or the Orange Pig? Ketamine; DXM; Caffeine; Crystal Meth; BZP

102. Subjective experiences can vary – be careful!

104. What goes up, must come down… Lack of sleep. Lack of food. Physically exhausted. Accept the comedown; chill out with friends. Depressed; irritable; cranky Need time for recovery Eat! Sleep! Spread out the partying… not every weekend. Serotonin takes a few weeks to be replaced.

105. Cocaine (powder) Coke, Blow, Charlie, Whitney White to cream chunks or powder $40 ½ gram; ~$240 8-ball [3.5 grams] (Toronto 2011) Typically snorted up the nose

106. Cocaine (powder) Main neurotransmitter: dopamine Stimulant Physical effects: Increase in heart rate, body temperature, blood pressure Numbs tissues it touches (nose, gums, lips) Jaw grinding, dilated pupils, upset stomach Psycho/behavioural effects: +ve: increased wakefulness; confidence; chatty -ve: cravings; anti-social; anxious; “edgy”  or  sex drive

107. Cocaine biochemistry Peak blood cocaine levels in approximately: 30 to 45 minutes (snorted) 5 minutes (smoked) Almost instantly (injected) Duration of action: 45 to 90 minutes Short half life (1-2 hours) Short high… Quick come down  desire to do more and to keep going

108. Cocaine biochemistry

109. Cocaine Immediate risks: Stroke; heart attack (esp. with high concentrations from high doses or extended “runs”) Anxiety / panic attacks Dehydration Push boundaries and take unintended risks Spend more than you intend Disease (esp. with snorting)

110. Cocaine Longer-term concerns: Tolerance Psychological / physical dependency Sinus infections Weight loss or gain Finances

111. Cocaine Risk Reduction Use a new straw Don’t snort with dirty dollar bills and keys. Avoid sharing straws or bumpers. Try colour coding or marking your straws when using with other people. Having a nasal spray of clean water, that you could use shortly after snorting each line. This can help reduce the damage to your nose. Leave money and bank cards at home.

112. Cocaine (crack) Rock; Free base cocaine; Powdered cocaine dissolved and boiled in a mix of ammonia or baking soda. Looks like rocks or chunks Price: varies by region; 1 hit for <$5 Smoked or injected Makes a cracking sound when burned

113. Cocaine (crack) Taken from erowid.org

114. Crack Risk Reduction Use your own equipment: Pipes, needles, cookers, filters, tourniquets… etc. Find a safe space to use. Carry condoms / lube. Moisturize lips with non-oil based products.

116. Pyrex-glass pipe

117. Rubber mouth piece

118. Heat resistant metal screens

119. Chopstick

120. Helps prepare screens

121. (Lip Balm)Video: Step-by-step demonstration of safer crack smoking: http://hepcinfo.ca/videoplayer_e/safer_smoking_e.flv

122. Cocaine – New Concerns Cocaine is notoriously cut with adulterants; it is rarely good quality. Recently an adulterant known as Levamisole is showing up in many samples throughout North America. This is of particular concern for people who are already susceptible to autoimmune disorders: Levamisole can significantly reduce the number of white blood cells in the body, a condition called agranulocytosis. Symptoms include fever, swollen glands, painful sores in the mouth and anus, and an infection that won't go away. Because many of the symptoms of the illness are the same as the flu, it is important that people who are using cocaine be aware that they aren't sick with something more serious than influenza.

123. Cocaine – New Concerns If you use cocaine watch out for: High Fever Chills Painful anal, oral sores Skin abscess / lung infection that appears to be developing more rapidly than usual. Seek Medical Attention Immediately!

124. Mephedrone Mephedrone, 4-MMC, Meow, M-Cat, Bubbles 2-Methylamino-1-p-tolylpropan-1-one Stimulant; Euphoriant A synthetic stimulant with empathogenic effects that some people report being a “cross between ecstasy and cocaine”. Between 2007 and 2009, it became available for purchase online, was used increasingly in Europe, Australia, and New Zealand, associated with several deaths, and then controlled in some countries as a result.

125. UK Mephedrone Ban May Have Done More Harm Than Good http://whyprohibition.ca/blogs/jesse-wentzloff/uk-mephedrone-ban-may-have-done-more-harm-good The [ban], which came after mephedrone had been linked to a number of deaths, which were later found not to be attributable to the drug, could be driving demand for other new drugs. It comes after recent research revealed that 40 new synthetic drugs have flooded into the UK during the past year

127. Methamphetamine It can also look like…

128. Methamphetamine Strong stimulant; “upper” Releases dopamine, serotonin, norepinephrine (adrenalin) Long half-life (12 hours) Physical effects: Increase in heart rate, body temperature; decreased appetite and sleep; dry mouth; loss of erection Psycho/behavioural effects: Increase in alertness, confidence, euphoria Paranoia; anxiety; decreased self control / inhibitions

129. The Role of Dopamine While all stimulants release some dopamine, crystal meth releases much larger amounts: Cocaine releases 400% more dopamine Crystal meth releases almost 1500% more dopamine

130. Methamphetamine Immediate risks: Dehydration Lack of food / sleep Loss of inhibitions Paranoia / psychosis

131. Methamphetamine Longer-term risks: Physical/psychological dependency Weight loss Tooth decay Strains on heart Depression Loneliness Loss of friends, school, job

132. Methamphetamine Risk Reduction Plan ahead before partying; you may need a few days to recover. Try to eat something while you're high Protein shakes or fruit juices with healthy supplements are better than nothing. Feed your body the fuel it needs. Limit what you buy. The longer you party the rougher you’ll feel. Use extra lube if having sex. Lack of sleep. Lack of food. Physically exhausted. Accept the comedown Spread out the partying… not every week. Dopamine and all those other neurotransmitters take time to be replaced.

133. GHB G, GHB Price = ~ $10 / vial Clear liquid with slight “chemically” smell and taste which can easily be masked in a drink

134. GHB Sedative; depressant; “downer” Lower dose: similar effect to alcohol… relaxed, happy sociable Higher dose: dizzy, sleepy, vomiting, muscle spasms, loss of consciousness (“G-d out”), depressed breathing Duration of high: 1-4 hours

135. GHB Immediate risks: Very dose dependant Can be extremely dangerous when mixed with alcohol Vomit pass out  aspiration Coma Longer-term risks: Psychological dependency Physical dependency

136. GHB Risk Reduction Store liquid G in a container that could never be mistaken for drinking water. Colour the mixture BLUE using food colouring, so as to avoid it being mistaken for water, juice or alcohol. Shake that bottle! GHB is heavier than water.

137. Ketamine Special K, K, kitty Price: $20 - $30 / vial White powder Looks similar to table salt or a fluffy powder Typically snorted Can be smoked or injected (IM)

138. Ketamine Source: wikipedia

139. Ketamine Anesthetic; “downer” Lower dose: mild, dreamy effect; numbness in extremities Higher dose: difficult to move; hallucinogenic effect: out of body feeling; separation of mind and body (“K-hole”) Duration of high: 30-60 minutes (K-hole) but after effects last longer

140. Ketamine Immediate risks: Falling (breaking a limb) Assault Nausea (aspiration) Disease (esp. with snorting)

141. Ketamine Longer-term risks: Tolerance Psychological/physical dependency Sinus infections (if snorting) Bladder infections Kidney problems “k-pains”

142. Ketamine Risk Reduction Caution should be exercised when measuring doses. It is best to start with very small doses, working your way toward the desired levels. Caution with eating before using. Anesthetics often make people throw-up. Avoid mixing with alcohol. Many users report getting sick this way.

143. Viagra Sildenafil® Tablets come in doses of 25, 50 and 100 mg. Other similar substances: Levitra, Cialis, Physical effects: Blood vessels relax; erection; lowered blood pressure Immediate risks: Stroke / heart attack Duration high: drug lingers in body for several hours

144. Viagra Symptoms of Viagra, Cialis or Levitra toxicity: Chest or jaw pain Irregular heartbeat Nausea Respiratory problems Visual disturbances (blue colour) Prolonged erection > 4 hours Get to emergency room!

145. Viagra Risk Reduction Use the smallest dose necessary Be extra cautious if using blood pressure medications Don’t take with grapefruit juice Be careful when - or try to avoid - mixing with poppers If erection lasts longer than 4 hours, go to emergency room

146. Viagra

147. Viagra? Off-prescription “Viagra”, Fall 2007, Toronto, Canada

148. Poppers bolt, climax, poppers, rush, Zbest, and others Butyl / amyl nitrite; vapor inhaled Physical effects: Relaxation of blood vessels and smooth muscle tissue Drop in blood pressure; flushed face Psychological effects: +ve: head rush; horny; less inhibited -ve: anxiety; nausea Duration high: 30-60 seconds

149. Poppers Immediate risks: Flammable; chemical burns Nausea; headaches Stroke (esp. mixed with other substances that lower blood pressure such as Viagra) Long-term risks: Psychological addiction; carcinogenic?

150. Alcohol Neurotransmitters: GABA (inhibits brain activity) Alcohol stimulates GABA receptors, making them more inhibitory and further inhibiting brain activity Glutamate (brain’s general purpose excitatory transmitter) Binds to glutamate receptors preventing glutamate from exciting the cell Alcohol particularly effects areas involved in memory formation, decision making and impulse control

151. Alcohol Risk Reduction Alcohol does not mix well with many substances. Be cautious, and better to avoid, the following: Alcohol + Benzos Alcohol + Ketamine Alcohol + Opiates Alcohol + GHB This can be a particularly dangerous combination

152. Alcohol Risk Reduction Eat something before drinking Pace yourself Hydrate as you drink Prearrange transportation; leave car keys behind Take only the money you intend to spend Make your own drinks Only accept drinks from people you trust Monitor how often you’re drinking; take breaks “Liquor before beer, you’re in the clear; beer before liquor, never been sicker” (Nearly all liquor is quality and potency assured)

153. Cannabis Marijuana, pot, weed. Commonly smoked or eaten. Concentrated resinous form called hashish, and as a sticky black liquid called hash oil. Synthetic (pharmaceutical) versions. Three distinct species Cannabis sativa, Cannabis indica, and Cannabis ruderalis The term 'hemp' is generally used to describe low-THC varieties of cannabis which are grown for industrial uses.

154. Cannabis Price = ~ $40 for 1/8 ounce (a “half quarter”, 3.5 grams) Green leaf plant with buds, with orange/brown fibers and sometimes coated in crystals.

155. Cannabis The active ingredients are called cannabinoids THC (Delta-9-tetrahydrocannabinol) is thought to be responsible for most of the psychoactive effects. Effects Onset: When smoked, the effects of cannabis begin almost immediately. When eaten the effects can take 1 to 2 hours to manifest. Duration: Effects of smoked cannabis peak after about 20 minutes and last for 1-2 hours. When eaten, the effects will peak more slowly and primary effects may last for 3-4 hours.

156. Cannabis Experience Primary effects with recreational use: Euphoria, relaxation, and changes in perception. Effects vary depending on dosage. Low doses: Sense of well-being, mild enhancement of senses (smell, taste, hearing), subtle changes in thought and expression, talkativeness, giggling, increased appreciation of music, increased appetite, and mild closed-eye visuals. Higher doses: Visuals may become more prominent, sense of time is altered, attention span and memory are frequently affected, and thought processes and mental perception may be significantly altered.

157. Cannabis Experience Primary reasons for medicinal use: Appetite stimulation Pain reduction Many other benefits reported for a wide variety of conditions. Can get a federal permit: To possess To grow To be a designated grower

158. Cannabis Concerns Negative effects can include: Paranoia, dry mouth, respiratory problems and nervousness/racing heart. Reduced ability to concentrate, impaired memory, tiredness, and confusion. Side effects tend to increase with lifetime use.

159. Cannabis Concerns Relative potential for dependency: Regular use can lead to psychological habituation making it difficult to quit. Most people do not experience signs of physical addiction. Withdrawal somewhat difficult but in no way dangerous. Benzodiazepines can be used to treat withdrawal.

160. Cannabis Concerns Long Term Health Problems: Smoking: lung and throat problems: coughing; increased throat and lung infections; reduced lung capacity; carcinogenic effects. Amotivational syndrome. Not (or slightly) toxic to the liver, but… Increasing concern around heavy/chronic use and HepC.

161. Cannabis Concerns Heart Issues: Because cannabis increases heart rate, it could potentially increase risks of heart problems in those at risk of heart disease. Mental Illness: Can precipitate neuroses or psychoses in those who are already at risk.

162. Cannabis Risk Reduction Know your source. Be careful about mould and bacteria. Eating poses lowest health risks, though harder to titrate (manage) dose. Use with people you trust. Be mindful of smoking public spaces. Avoid getting high and driving. Smoking increases risks of pulmonary disease. Try a vaporizer instead of smoking.

163. Cannabis Risk Reduction Vaporizers offer and alternative to smoking. Cannabis is heated to the point THC vaporizes but the plant material is not burned. Cannabis before (left) and after (right) vaporization. This vaporizer relies on convection rather than conduction.

164. Vaporizer vs. Smoking Vaporizer after 2 months use (left) Pipe after 2 weeks use (right)

165. Synthetic (prescription) THC Synthetic THC, available on prescription Cesamet (nabilone); Marinol (dronabinol) Reduced psychoactive effects.

166. LSD (d-lysergic acid diethylamide) Potent hallucinogen White crystalline powder that dissolves in water, is odourless, and has a slightly bitter taste. An effective dose is too small to see. (20 - 80 micrograms) It is usually packaged in squares of LSD soaked papers (blotters) or miniature powder pellets called microdots Usually taken by mouth and held on the tongue or swallowed

168. colourful designs often added to mask impurities

170. LSD Alters the persons perception of reality. Can vividly distort the senses. “Trip” - perceptual changes, altered time sense, feeling detached from self, synesthesia (“hearing” colours), dizziness, “pins and needles” Not addictive Can cause flashbacks

171. PsilocybinStreet names: Magic Mushrooms, shrooms Hallucinogen, similar to LSD Mushrooms or in powder capsules Sniffed, smoked or injected, or ingested orally Onset 1/2 hour Effects last 4 to 5 hours

172. Effects of Psilocybin Sensations of relaxation or fatigue; separation from surroundings; heaviness or lightness Perceptual distortions, visual hallucinations, dizziness, shivering Can cause tension and anxiety shortly after ingestion

173. Is Psilocybin Dangerous? One danger is misidentification, as some mushrooms are poisonous PCP and LSD are often sold as psilocybin Can impair judgement Can trigger underlying mental health problems and cause schizophrenic-type symptoms User can have “bad trips”

174. Tryptamines - AMT (Alpha-methyltryptamine) Lasts 16 hours Effect like combining MDMA & LSD Wide range of experiences Comes in a white powder Can be swallowed, snorted or smoked $20 – 25 Only a small amount needed Narrow dose range 10 – 15 mg. Can cause unpleasant trips

175. Tryptamines 5-MEO-DIPT Foxy-methoxy White powder or tablet 5 – 12 mg. Dose $30 – 40 per dose Causes body buzz, mood lift, euphoria, increased sex drive, and enhanced visuals Long lasting Can cause acute vomiting, long come down (12 hours), diarrhoea, a widely varied experiences.

176. Tryptamines - 2CB White powder or tablet $30 per dose MDMA/LSD effect Open and closed eye visuals Mild stimulant and mood enhancer Can cause cramps and diarrhoea Lasts 4 to 6 hours Life altering Tolerance develops quickly

177. Tryptamines - 2CT7 Powder or tablet 7 mg tabs sometimes sold as “E” Change in perception & time Increased sociability Dissociative effect May cause anxiety, confusion or panic attacks Nausea and vomiting Has resulted in death

178. Research Chemicals Substances used in medical research Popularized by fringe scientist and doctor, Alexander Shulgin 2CI, 2CB, 2CT2, 2CT7, 5-meo-DiPT. 5-meo-AMT, BZP, TFMPP, mephedrone Many are legal, some are scheduled substances Can easily be obtained over the internet The ones with psychedelic properties are sought

179. Research Chemicals Scheduling of these substances causes ‘blow-out sales’ by manufacturers, who are eager to get rid of them to anyone with a credit card Come in ‘waves’ through the dance music scene

180. Research Chemicals Little is known of these substances, their long-term effects, potential contraindications with medications and other drugs Not a very high success rate: with several of the substances, only 50% of users will get the desired high, the other 50% will have vomiting and diarrhea

182. Opium

183. Fentanyl

184. Morphine (& MS-Contin) (“peelers”)

185. Hydromorphone (Dilaudid, Hydromorph-Contin)

186. Oxycodone (Percocet, Percodan)

187. Codeine

188. Hydrocodone (Hycodan)

189. Meperidine (Demerol)

190. Substitute: Methadone

191. All are downers

193. Mainly administered IV

194. Also snorted and smoked

195. ± $50 a point (1/10 of a gram)

196. Intense feeling of euphoria and well-being

197. Sedation, analgesia

199. Prescription opioids are the predominant form of illicit opioid use.

202. 12-hour pain relief.

203. In Canada, OxyContin is manufactured by Purdue Pharma.

204. Introduced in 1996; Oxycodone-based products have been used illicitly for the past 30 years.

206. Usually prescribed as a trans-dermal time release patch

207. 5 strengths with 1.25, 2.5, 5.0, 7.5, 10 mg

208. Delivers 12, 25, 50, 75, 100 mcg/hr for 72 hours

209. People will scrape the patch and inject the fentanyl

210. One patch can give about 10 injections

212. Medications can assist with detoxification in combination with other therapeutic interventions.

213. In Canada, methadone maintenance has increased five-fold since the mid-1990s

215. A decrease in the use of other substances.

216. A substantial decrease in crime and prostitution.

217. Improved health (except for preexisting infections).

218. An improvement in living conditions.

220. Pharmaceutical Drugs The following few slides come from: not4me.org We have divided the pharmaceutical facts into three common categories: Opioid Painkillers Stimulants Tranquilizers, Barbiturates

221. Pharmaceutical Opioid Painkillers What it is Category: Opioid analgesic Examples of generic names (and their respective trade names) include: codeine (Tylenol III), meperidine (Demerol), hydrocodone (Vicodin), oxycodone (OxyContin, Percocet) and morphine. Pharmaceutical painkillers are usually prescribed medically for the purposes relieving pain, but they are also used recreationally or outside of their prescribed use. Most opioid painkillers that are used recreationally are diverted from prescription use, rather than being illegally manufactured. Most come in pill form in various dosages, which can be taken orally, ground up and snorted nasally or diluted into a liquid and injected. Snorting and injecting result in a quicker and stronger effect (though these methods can be very dangerous as they release several hours worth of opioid painkillers into your body at once).

222. Pharmaceutical Opioid Painkillers What will likely happen *Reactions and experiences may vary dramatically from person to person.* Effects on brain: Short term:Opioid painkillers activate opioid receptors in the brain, increasing the release of the neurotransmitter dopamine, interfering with the transmission of pain signals to the brain and causing feelings of intense happiness, warmth and pleasure. Effects on body: Short term: Possible immediate effects include (pain relief), sleepiness, constricted pupils, sweating, loss of appetite, constipation, nausea, vomiting, dizziness, headache, itchiness, dry mouth, fatigue, weakness, insomnia, fever, diarrhea, difficulty urinating, abdominal pain, rash, difficulty breathing and convulsions. When snorted, nasal discomfort or damage can occur. Long term: Possible long term effects include physical addiction and withdrawal symptoms if drug use is stopped. Some opioid painkillers (such as codeine and hydrocodone) also contain acetaminophen, which can cause liver toxicity with regular use and high doses. Effects on behaviour: Short term: Possible immediate effects include improved mood, euphoria, feelings of relaxation, unfocused thoughts, confusion, and nervousness. Long term: Possible long-term effects include cravings for more opioid painkillers and decreased interest in sex.

223. Pharmaceutical Opioid Painkillers Dependency Addiction: Opioid painkillers can be both physically and psychologically addictive. The addictive potential is strong in recreational users as well as in medical users, especially if the drug is used on a daily basis. Tolerance: Tolerance to opioid painkillers can develop over a matter of weeks, with higher doses needed to achieve the same desired effect (both recreationally and medically). Withdrawal Symptoms: Symptoms can occur when regular pharmaceutical painkiller use is stopped, and include insomnia, restlessness, muscle spasms, muscle aches, tremors, sweating, fever, nausea, vomiting, diarrhea and anxiety.

224. Pharmaceutical Opioid Painkillers If you choose to use... Harm Reduction Tips Recreational use of pharmaceuticals is illegal; therefore if you are caught possessing pharmaceuticals without a prescription from your doctor, or exchanging, buying or selling them, it can result in criminal charges. Drug use affects the developing mind and body differently than developed ones. Waiting until your mind and body have more fully developed before using substances can have long term health and mental benefits. Opioid painkillers have very strong addictive potential! Do not assume that a drug prescribed by a doctor to a friend will be safe for you to take as well. Opioid painkillers are prescribed only for individuals who need it, and can have adverse and dangerous effects on individuals for whom they are not prescribed. Similarly, if you have been prescribed opioid painkillers, avoid taking more than the prescribed dosage. Always talk to your doctor or a health professional before taking prescribed painkillers with other substances. Some of the negative effects of opioid painkillers can be alleviated by lying down. Negative side effects generally increase with higher doses.

225. Pharmaceutical Opioid Painkillers Some opioid painkillers (such as codeine and hydrocodone) also contain acetaminophen, which can cause liver toxicity with regular use and high doses. If injecting, use new, clean syringes and equipment. Prepare your shot on a clean surface. Clean the area you are planning to inject with soap and water or an alcohol pad. You can get clean injection supplies from a syringe exchange, a pharmacy, or your local health department. If you can’t get new needles, try snorting instead. Cleaning needles and works is not risk-free; it’s a last resort. Rinse with cool water 3 times, bleach for 30 seconds, then clean water 3 times. Regular injection can cause abscesses, collapsed veins, infections and other complications. Regular snorting can cause serious damage to the nose such as a chapped, runny nose, sinus infections, nose bleeds and developing a hole in the cartilage wall between nostrils. Avoid sharing equipment (straws, syringes, spoons) since this could lead to transmission of Hepatitis B, Hepatitis C and HIV Snorting and injecting opioid painkillers can result in a quicker and stronger effect. These methods can be very dangerous as they release several hours worth of opioid painkillers into your body at once. Avoid using opioid painkillers with other substances, particularly depressants such as alcohol and narcotics.

226. Pharmaceutical Stimulants What it is Category: Stimulants Examples of chemical names (and their respective trade names) include: amphetamine (Adderall) and methylphenidate (Ritalin, Concerta). Pharmaceutical stimulants are most commonly prescribed in the treatment of Attention Deficit Disorder (ADD) and Attention Deficit Hyperactive Disorder (ADHD), but they have also been used in the treatment of narcolepsy and mild depression. Pharmaecutical stimulants are also used recreationally or outside of their prescribed use by many individuals. For more information about amphetamines, click here.

227. Pharmaceutical Stimulants What will likely happen *Reactions and experiences may vary dramatically from person to person.* Effects on brain: Short term: Stimulants cause an increased release of the neurotransmitter dopamine which causes increased feelings of pleasure. Long term: can cause permanent changes to some areas of the brain, though the brain is quite adept at rewiring and compensating for changes Effects on body: Short term: Possible immediate effects include sweating, dilated pupils, decreased appetite, difficulty sleeping, tremors, increased heart rate, increased blood pressure, narrowing of blood vessels causing decrease in blood flow and flow of oxygen to the heart. Long term: Possible long term effects include weight loss, insomnia, exhaustion, heart problems, seizures, physical addiction and withdrawal symptoms is drug use is stopped. Effects on behaviour: Short term: Possible immediate effects include increased concentration, panic, anxiety, aggression, hostility, violence and paranoia. Long term: Possible long-term effects include paranoia, aggression, panic, hostility, violence and triggering of underlying psychological problems.

228. Pharmaceutical Stimulants Dependency Addiction: Physical and psychological addiction can occur. Tolerance: can develop tolerance Withdrawal Symptoms: Withdrawal symptoms occur when stimulant use is stopped and include, depression, loss of appetite, difficulty sleeping.

229. Pharmaceutical Stimulants If you choose to use... Harm Reduction Tips Recreational use of pharmaceuticals is illegal; therefore if you are caught possessing pharmaceuticals without a prescription from your doctor, or exchanging, buying or selling them, it can result in criminal charges. Drug use affects the developing mind and body differently than developed ones. Waiting until your mind and body have more fully developed before using substances can have long term health and mental benefits. Do not assume that a drug prescribed by a doctor to a friend will be safe for you to take as well. Pharmaceutical stimulants are prescribed only for individuals who need it, and can have adverse and dangerous effects on individuals for whom they are not prescribed. Similarly, if you have been prescribed pharmaceutical stimulants, avoid taking more than the prescribed dosage. Always talk to your doctor or a health professional before taking prescribed stimulants with other substances. Avoid sharing equipment (straws, syringes, spoons) since this could lead to transmission of Hepatitis B, Hepatitis C and HIV If injecting, use new, clean syringes and equipment. Prepare your shot on a clean surface. Clean the area you are planning to inject with soap and water or an alcohol pad. You can get clean injection supplies from a syringe exchange, a pharmacy, or your local health department. If you can’t get new needles, try smoking or snorting instead. Cleaning needles and works is not risk-free; it’s a last resort. Rinse with cool water 3 times, bleach for 30 seconds, then clean water 3 times. Regular injection can cause abscesses, collapsed veins, infections and other complications. Regular snorting can cause serious damage to the nose such as a chapped, runny nose, sinus infections, nose bleeds and developing a hole in the cartilage wall between nostrils.

230. Pharmaceutical Tranquilizers, Barbiturates What it is Category: Sedative, tranquilizer Examples of generic names (and their respective trade names) include: diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), clonazepam (Klonopin), amobarbital (Amytal) and pentobarbital (Nembutal). Pharmaceutical tranquilizers and barbiturates are usually prescribed medically for the purposes of treating anxiety, sleep problems, muscle spasms and seizures, but they are also used recreationally or outside of their prescribed use. Most tranquilizers and barbiturates that are used recreationally are diverted from prescription use, rather than being illegally manufactured. Most come in pill form in various dosages, which can be taken orally, ground up and snorted nasally or diluted into a liquid and injected.

231. Pharmaceutical Tranquilizers, Barbiturates What will likely happen *Reactions and experiences may vary dramatically from person to person.* Effects on brain: Short term: Pharmaceutical tranquilizers and barbiturates increase the activity of the neurotransmitter GABA, resulting in decreased brain activity and causing feelings of calmness and drowsiness. Effects on body: Short term: Possible immediate effects include dilated pupils, drowsiness, slurred speech, loss of coordination, fatigue, irregular breathing, decreased heart rate, decreased blood pressure. Long term: Possible long term effects include slower reflexes, chronic tiredness, problems with vision, difficulty sleeping, sexual dysfunction, respiratory difficulties and liver damage. Effects on behaviour: Short term: Possible immediate effects include feelings of calmness and relaxation, lowered inhibitions, impaired judgment and paranoia. Long term: Possible long-term effects include mood swings and aggression.

232. Pharmaceutical Tranquilizers, Barbiturates Dependency Addiction: Pharmaceutical tranquilizers and barbiturates can be both physically and psychologically addictive. The addictive potential is strong in recreational users as well as in medical users, especially if the drug is used on a daily basis. Tolerance: Tolerance to pharmaceutical tranquilizers and barbiturates can develop very quickly, for both medical and recreational use, particularly when taken on a daily basis. Withdrawal Symptoms: Withdrawal symptoms do occur when regular use or high doses are stopped and include restlessness, insomnia, anxiety, depression and delirium. One severe withdrawal symptom is brain activity rebound, as the tranquilizers or barbiturates wear off, resulting in the brain racing out of control. This can sometimes cause seizures.

233. Pharmaceutical Tranquilizers, Barbiturates If you choose to use... Harm Reduction Tips *Disclaimer! Nothing you do can make using unprescribed pharmaceuticals completely safe. All drug use has inherent risks and dangers. The suggestions in this section can only help you reduce some of the associated risks. The best way to avoid the harms related to drug use is to not take the drug at all.* Recreational use of pharmaceuticals is illegal; therefore if you are caught possessing pharmaceuticals without a prescription from your doctor, or exchanging, buying or selling them, it can result in criminal charges. Drug use affects the developing mind and body differently than developed ones. Waiting until your mind and body have more fully developed before using substances can have long term health and mental benefits. Avoid sharing equipment (straws, syringes, spoons) since this could lead to transmission of Hepatitis B, Hepatitis C and HIV If injecting, use new, clean syringes and equipment. Prepare your shot on a clean surface. Clean the area you are planning to inject with soap and water or an alcohol pad. You can get clean injection supplies from a syringe exchange, a pharmacy, or your local health department. If you can’t get new needles, try snorting instead. Cleaning needles and works is not risk-free; it’s a last resort. Rinse with cool water 3 times, bleach for 30 seconds, then clean water 3 times. Regular injection can cause abscesses, collapsed veins, infections and other complications. Regular snorting can cause serious damage to the nose such as a chapped, runny nose, sinus infections, nose bleeds and developing a hole in the cartilage wall between nostrils. Do not assume that a drug prescribed by a doctor to a friend will be safe for you to take as well. Tranquilizers and barbiturates are prescribed only for individuals who need it, and can have adverse and dangerous effects on individuals for whom they are not prescribed. Similarly, if you have been prescribed tranquilizers or barbiturates, avoid taking more than the prescribed dosage. Always talk to your doctor or a health professional before taking prescribed medications with other substances.

234. Pharmaceutical Risk Reduction Harm Reduction Guide to Coming Off Psychiatric Drugs: http://theicarusproject.net/downloads/ComingOffPsychDrugsHarmReductGuide1Edonline.pdf

235. Interactions with HIV meds Many recreational drugs may be dangerous when combined with HIV medications, based on individual case reports, and what we know about how the body processes these drugs. Most interactions between recreational drugs and HIV medications have not been scientifically studied, nor are they likely to be, given that most are illegal substances. However, people have shown through experience that “safer partying” is possible, and there are some specific tips that can help make drug use safer and healthier. Drug Interaction Tables Immunodeficiency Clinic Toronto General Hospital www.hivclinic.ca/main/drugs_interact.html

236. Resources General: www.erowid.org/psychoactives/psychoactives.shtml (all about every drug) www.tripproject.ca (Toronto based “party drug” harm reduction) www.not4me.org (Fear and abstinence only drug education?It's not enough 4 me.) www.torontovibe.com (AIDS Committee of Toronto’s party drug info page) www.dancesafe.org (U.S. based “party drug” harm reduction info) www.cssdp.org (Canadian Students for Sensible Drug Policy) Ecstasy: www.ecstasy.org www.ecstasydata.org (chemical analysis of pills) www.pillreports.com (qualitative user reports of pills) Crystal Meth: (gay/bi men focused) www.himynameistina.com www.tweaker.org / www.crystalneon.org www.knowcrystal.org

237. Existing Supports Detox, pre-treatment, treatment, post-treatment, complementary approaches DART (info about treatment) www.dart.on.ca 1.800.565.8603 24 hrs; anonymous; confidential Centre for Addiction and Mental Health (CAMH) Assessment: 416.535.8501 X 6616

238. Existing Supports YSAP – Youth Substance Abuse Program at YMCA Counselling and Education http://www.ymcatoronto.org/en/who-we-work-with/educators/substance-abuse/index.html Mississauga151 City Centre Drive, Suite 800905-276-9322 Brampton8 Nelson Street, Suite 306905-450-9001 Toronto485 Queen Street West, 3rd Floor 416-504-1710 Scarborough230 Town Centre Court416-296-9907 ext. 401

240. www.knowcrystal.org- www.tweaker.org - www.crystalneon.org - www.torontovibe.com Rainbow Services – CAMH (LGBT addictions counselling) Weekly meetings; 3 week sessions; 416.535.8501 x 6784 AIDS Committee of Toronto Counselling Staff Primarily if concerned about behaviour but not looking to change use