Dangerous Liaison: Club Drug Use and HIV/AIDS

• Introduction
• Raves and Circuit Parties
• Club Drugs
• Drug Use, Sex, and the Risk of HIV
• The Effects of Club Drugs on HAART and Adherence to HAART
• Adherence
• Prevention and Harm Reduction
• Role of the Physician and Allied Healthcare Professionals
• Conclusions
• References

Introduction

Club drugs, or recreational drugs, as they are sometimes called, have only recently been associated with increased high-risk sexual behaviors which, in turn, may cause higher incidence of HIV/AIDS. By club drugs, we mean a number of illegal, mostly synthetic drugs that are commonly used in nightclubs, "raves," and circuit parties.¹ In this article, we will be referring to club drugs and recreational drugs interchangeably.

Injection drug use has been known almost since the outbreak of the epidemic to be a means of spreading the virus by way of contaminated blood. In recent years, it has become increasingly clear that injection drug users (IDUs) are not only at increased risk of HIV infection from infected needles and shared drug paraphernalia but also as a result of high-risk sexual behaviors. The latter include trading sex for money and unprotected sex fueled by high sex drive associated with cocaine and amphetamine use.²

Even among short-term young IDUs, sexual practices, and not just injecting practices, were found to be important predictors of HIV infections.³ Gay and bisexual men who inject drugs appear to be at greatest risk, as indicated, for example, by their HIV seroprevalence increasing in San Francisco from 25 percent in 1996 to 42 percent in 2000, while heterosexual male IDUs remained at a stable rate.⁴

A study by Strathdee et al. followed 1,800 IDUs for 10 years in Baltimore and found that high-risk sexual behavior was a better predictor of HIV infection than was sharing needles while injecting drugs. They found a gender difference in the type of sexual activity that predicted greatest risk, however. Among men, high-risk homosexual activity was the best predictor. Among women, high-risk heterosexual activity was the most important factor.⁵

Club drug users, not wanting the stigma or risks of injection drug use, prefer drugs such as MDMA (Ecstasy), ingested in pill form. This allows users to avoid track marks, and other signs of hard drug use and contribute to a belief that taking club drugs is harmless as well as fun.⁶

Particularly in the gay/bisexual community, drugs such as MDMA have become increasingly popular within a significant drug-using subset. A large probability telephone sample of urban men who have sex with men (MSMs) taken at four large American cities found a 52 percent prevalence of recreational drug use.⁷ A separate study in New York City found that 13.7 percent of a sample of MSMs reported using MDMA within the past six months, using it an average of 6.24 times in that period. Compared with non-users, MDMA users were found to have more male partners, have more one-night stands with men, and have more unprotected anal sex with men.⁸ There was clearly an association between club drug use and high-risk sexual behaviors.

This article will examine club drugs, their effects and risks, as well as some of the settings in which they are used. We will also look at the relationship between drug use, sexual behavior, and risk for HIV/AIDS. We will discuss how recreational drugs may interact with highly active antiretroviral therapy (HAART). We will also look at some of the efforts that have been made in prevention and harm reduction strategies to reduce the transmission of HIV. Finally, we will discuss the role of the physician or allied health professional in assessing and treating the drug abusing or dependent patient with or at risk for HIV/AIDS.

Raves and Circuit Parties

Raves have become increasingly popular since the 1980s. They are nighttime dance parties originally held in large, abandoned warehouses or in farm fields and more recently in legal spaces such as concert halls and underground parking lots.⁹ Attendance has been as high as 20,000 participants. Raves attract primarily middle-class heterosexual 15- to 25-year-olds who hear about them on the Internet or by word of mouth. They can involve up to two days of dancing, lights, and electronic music, often presided over by a popular DJ. Raves are characterized by consumption of club drugs in "cafeteria" fashion, in which whatever drugs are available are often sampled. The pills often contain adulterants which may be more toxic than the club drug itself. Also, as drugs are combined during the same event, undesirable and unpredictable effects can result.^10,11

Circuit parties have also grown in popularity and are common throughout the world. They are large-scale dance events that last for several days and tend to occur each year at about the same time in a particular city. These annual events are so named because they appear to follow a circuit from one city to another every few weeks.¹²

Unlike raves, circuit parties are attended primarily by gay and bisexual men who come to participate in late-night dance events, as well as in multi-event entertainment such as popular singers, all male revues, and frequently homoerotic events. Large parties can attract 20,000 men to a particular community. This is typically a somewhat older crowd than those attending raves, often upper-middle-class white men in their 30s.^12,13

More than 80 percent reported drug use during these events, according to one recent study.¹⁴ According to the Circuit Party Men's Health Survey of the San Francisco Bay Area,¹³ 78 percent of the participants were between 25 and 39, attended a median of three parties in the previous year, and a significant number (25 percent) reported at least one incident of drug overuse during that same time. Most of the men had taken MDMA or ketamine, as well as other popular substances, during the most recent circuit party weekend. While nearly all participants were motivated by the desire "to listen to music and dance," and "to be with friends," a majority of men endorsed "getting high on drugs" as a motivation, whereas nearly a third were there to "have sex." When the authors compared three-day drug use rates with six-month rates from a general population sample of gay men,⁷ men reported much lower use of amphetamines, cocaine, and Ecstasy during the six-month time period. Mansergh et al. conclude that a "substantial drug culture permeates the circuit party environment."

Some organizations that provide case management, medications, and other services to persons with HIV/AIDS, such as AIDS Arms, Inc., in Dallas, have refused to be a recipient of funds from these events (circuit parties) because of the illicit drug use "that dramatically impair[s] an individual's judgment increasing the likelihood of engaging in unsafe sexual practices."¹⁵

Club Drugs

The U.S. National Institute of Drug Abuse (NIDA) describes club drugs as a vague term that refers to a wide variety of drugs that grew in popularity along with dance club culture in the 1990s. Older party drugs such as cocaine, popular in the 1980s, are not as widely used since their health risks have become more widely known. Drugs that have become increasingly abused include methamphetamines, 3,4-methylenedioxymethamphetamine (MDMA), gamma-hydroxybutyrate (GHB), flunitrazepam (Rohypnol), and ketamine. Each can cause serious health problems, and even death, in spite of a popular misconception that taking them is a safe way to enhance the dance party experience.⁶ In the United States, 9.1 percent of college students and 7.2 percent of young adults (ages 19-28) reported in 2000 that they used MDMA at least once in the last year.¹⁶ Similarly, a study of over 3,000 university students in the United Kingdom reported that 13 percent had used MDMA.¹⁷ Winstock et al. reference reports of use and related problems in Denmark, Germany, Spain, Australia, and the Netherlands.¹⁸

3,4-Methylenedioxymethamphetamine (MDMA)

Street Names: Ecstasy, X, E, Adam, Hug Drug

Ecstasy is an amphetamine with both stimulant and hallucinogenic properties. It is usually taken orally as a tablet or capsule. It is used to reduce inhibitions and create feelings of empathy for others as well as deep relaxation. The stimulant effect allows the user to stay up all night, as its effects last four to six hours. With repeated use, the user may stay up for two- to three-day parties.^1,19 It can produce significant increases in heart rate, myocardial oxygen consumption, and blood pressure, which is particularly risky for persons with circulatory or heart disease.

MDMA, along with other popular substances, such as alcohol, is used for extended dancing in hot and crowded conditions. These factors increase its toxicity and lead to dehydration, hyperthermia, seizures, kidney and cardiovascular system failure, and may lead to death.^20,21

Regular use causes lasting damage to neurons that release serotonin, changes that have been shown to persist for many years in animals, and may cause memory impairments, disrupted sleep, depression, and anxiety. Studies in Great Britain and Germany found that MDMA users, even after six months of non-use, performed more poorly on some memory and learning tests than non-users.²⁰

A case study of club drug using MSMs in Boston and New York found that more than 50 percent of the men in the study combined MDMA with other drugs such as ketamine, cocaine, methamphetamines, and Viagra.²²

Gamma-Hydroxybutyrate (GHB)

Street Names: Liquid Ecstasy, Grievous Bodily Harm, G, Georgia Home Boy, Fantasy

GHB is a central nervous system depressant banned by the U.S. Food and Drug Administration (FDA). It generates feelings of euphoria, sedation, and well-being, and can also be used to counteract over-stimulation by MDMA. It is available in clear liquid or a white powder that can be added to water and mixed with flavorings. It may also be sold as a capsule or tablet.¹⁹

Adverse effects include its ability to slow down breathing and heart rate to dangerous levels. At lower dosages, it causes sedation, nausea, and visual changes. Overdose may occur rather quickly, and can lead to seizures, hypothermia, loss of consciousness, coma, and ultimately death. In 1999, there were 2,960 medical emergencies related to GHB use in the United States compared to 790 in 1998.²³ As of January 2000, the U.S. Drug Enforcement Agency (DEA) reported 60 GHB-related deaths.¹

GHB has also been implicated in sexual assaults and is considered a "date rape" drug. It can cause the victims to be incapable of resisting rape and to have difficulty remembering the details of the assault at a later time, rendering them unreliable witnesses.¹ It has been incorrectly perceived as a safe drug because, until recently, it was available in health food stores as a supplement.²³

Ketamine

Street Names: K, Special K, Vitamin K, Cat Valium, Horse Tranquilizer

Ketamine is marketed as a short-acting general anesthetic for human and veterinary use. As a liquid or powder, it can be injected, added to smokable materials, or consumed in drinks. It produces dreamlike or hallucinatory effects.^19,24 Low doses produce a mellow, colorful experience whereas higher doses can create "out of body" or "near death" experience, loss of consciousness, delirium, amnesia, seizures, and even, in some cases, fatal respiratory events.^1,25

When combined with alcohol, the greatest risk is falling asleep or collapsing, and then vomiting and possibly choking on one's own emesis.²⁶

Flunitrazepam (Rohypnol)

Street Names: Roofies, Roche, Forget-me pill, Mexican Valium, Rope, Ropies, Roaches

Rohypnol is a benzodiazepine illegal in the United States but available in many countries as a sedative or presurgery anesthetic. It can be taken orally in tablets or dissolved in drinks even without the person's knowledge, since it is tasteless and odorless.

It is known as a date rape drug because it can render its victim helpless and unable to remember clearly what took place. It can also lower blood pressure and cause drowsiness, dizziness, confusion, and visual disturbances.^1,19

Methamphetamine

Street Names: Speed, Ice, Crank, Meth, Fire, Glass, Crystal

Methamphetamine is a very addictive stimulant. It is a white powder that can be snorted, smoked, injected, or taken by mouth. It has become an alternative to MDMA at some clubs and raves although it is not as popular as other synthetic drugs at these settings. Like MDMA, it is used for high levels of energy needed in raves, clubs, and circuit parties, as well as for feelings of euphoria, increased self-confidence, and hypersexuality.^1,27

Abuse can result in damage to the central nervous and cardiovascular systems, irritability, hypothermia, aggressiveness, paranoia, and anxiety, as well as strokes, myocardial infarctions, and permanent damage to the blood vessels. Long-term use has been linked to an induced paranoid psychosis associated with delusions of persecution and hallucinations.²⁷

In the major metropolitan areas of the western United States and their gay communities, it seems to be reaching epidemic levels of abuse.²⁸ It also appears to be on the rise among sexually active gay men in New York City.²⁷

d-Lysergic Acid Diethylamide (LSD)

Street Names: Acid, Yellow Submarines, Cubes, Trips

This powerful hallucinogen is easily available at concerts and raves. Its potency varies from 20 to 80 micrograms per dosage unit, much less than the 100 to 300 microgram dosages common in the 1960s. It is now distributed in thin squares of gelatin, treated sugar cubes, or applied to blotter paper. At today's lowered potency, fewer emergency room visits occur, accounting for some of its continuing popularity.¹

LSD produces distortions in sensory perceptions and rapid mood swings, ranging from intense fear to euphoria.²⁵ Typically, the effects of the drug include higher body temperatures, increased heart rate and blood pressure, sweating, sleeplessness, and tremors. Long-term effects include persisting perception disorders known as "flashbacks."¹⁹

Sildenafil (Viagra)

Viagra is being combined with such club drugs as MDMA to enhance sexual experience. In a study in a sexually transmitted disease clinic in San Francisco, 32 percent of gay respondents and 7 percent of heterosexual male respondents reported using Viagra.

Combinations such as amyl nitrite (poppers) and Viagra can result in priapism, myocardial infarctions, and stroke. Gay men who use Viagra report more sexual partners and more risky sex (partners who are HIV-positive or are of unknown HIV status) than straight men.²⁹

A study of more than 2,000 night club customers in the United Kingdom found 3 percent who reported using Viagra recreationally, usually simultaneously with illegal drugs such as cocaine, methamphetamines, or cannabis. They reported feeling enhanced sexual desire and "warmth." Less than half reported negative effects such as headaches and genital soreness.³⁰

Drug Use, Sex, and the Risk of HIV

The relationship between drug use and unsafe sexual practices among gay men has been shown in many studies.^27,31-33 These unsafe sexual practices put gay and bisexual men at greater risk for HIV infection. Gay and bisexual men who do not use drugs report fewer acts of insertive and/or receptive anal intercourse without condoms than do recreational drug-using gay and bisexual men.³⁴

Methamphetamine shows documented prevalence rates ranging between 5 percent and 25 percent of the gay and bisexual men studied across many cities from Honolulu to Denver.²⁷ It is used to increase sensory experiences, especially sexual ones, and to create feelings of euphoria, which may contribute to increased sexual risk-taking. It has been associated with infrequent use of condoms, perhaps as a result of the above factors.³⁵

Methamphetamines can also increase risk for HIV/AIDS by increasing sexual sensation at the same time that it may interfere with erections, colloquially referred to as "crystal dick." A result of this problem can create "instant bottoms," a term applied by gay and bisexual men to drug users who take on the receptive role during anal intercourse. This practice is the riskiest sexual behavior that may cause HIV infection,³⁶ particularly when condoms are not used. Gay and bisexual men who use amphetamines have 2.9 times greater risk of HIV infection through receptive anal intercourse than men who do not use the drug.²⁷ Use of any stimulant drug, not just methamphetamines, has been associated with unprotected anal intercourse.³⁷

MDMA was reported to be in wide use among gay and bisexual men recruited from three dance clubs in New York City,¹⁴ and was found to be the only recreational drug associated with unsafe sex in this sample. Other drugs have been related to high-risk sexual behavior in different studies.^32,38-40

Circuit party weekends have also been associated with high-risk sexual behavior. A study by Mansergh et al. reported that 29 percent of their sample of gay and bisexual men had multiple sex partners during a single circuit party weekend. Of this higher-risk group, 47 percent reported unprotected anal sex. They concluded that sexual activity, including unprotected anal sex, was relatively common during these weekends.¹³

Colfax and his associates studied 295 gay/bisexual men in San Francisco and measured drug use and sexual risk-taking during a San Francisco circuit party (CP), a circuit party held in another geographical area (distant CP), and non-CP party weekends. They found a high use of drugs during CPs. For example, at a distant CP, 80 percent used MDMA, 66 percent used ketamine, and 43 percent used crystal methamphetamines. Drug use during CP weekends was greater than during non-CP weekends.

Unprotected anal sex with partners of unknown or opposite HIV serostatus was most prevalent during distant CP weekends, perhaps because the gay/bisexual men felt less inhibited away from their own city and took more sexual risks. The strongest predictors of unprotected anal sex with opposite or unknown serostatus partners were being HIV-positive and use of crystal methamphetamines, Viagra, or amyl nitrites. The authors conclude that the level of high-risk activity during circuit parties suggests significant potential for HIV transmission.⁴¹

In another study on circuit parties, Mattison et al. found that use of amyl nitrites (poppers), MDMA, ketamine, crystal methamphetamines, and GHB were associated with unsafe sex. In a large nonrandom sample of party attendees, more than 50 percent reported using alcohol, MDMA, and ketamine. Frequent use of MDMA, ketamine, and poppers had a significant association with unsafe sex at parties. Crystal methamphetamines and GHB only showed a trend although in the expected direction.⁴²

Chesney et al. suggest that seroconversion may be mediated by these drug-related factors:

1. Stimulants and inhalants increasing arousal and delaying ejaculation.

2. Disinhibition effects of drugs.

3. Substance abuse and high-risk sexual behaviors occurring within social networks if unprotected anal intercourse is a norm in such networks and there is a high-risk background prevalence of HIV.⁴³

Club drugs, in particular MDMA, methamphetamines, and poppers, encourage risky sexual practices, at least among gay/bisexual men, such as multiple sexual partners and unprotected anal or receptive anal intercourse, and thus increase the risk of HIV/AIDS. Circuit parties, especially distant circuit parties, encourage high-risk sexual behaviors and club drug use among gay and bisexual men. We are not aware of studies focusing on raves with a primarily heterosexual population and increased risk for HIV/AIDS.

The Effects of Club Drugs on HAART and Adherence to HAART

Club drugs can affect HAART both through drug interactions and by affecting adherence to HIV drugs. Interestingly, although alcohol interacts with many club drugs, alcohol appears to have the least interactions with protease inhibitors and non-nucleoside reverse transcriptase inhibitors. Methamphetamines and MDMA have a potential interaction with all of the protease inhibitors and delavirdine. GHB has a potential interaction with ritonavir. Marijuana has a potential interaction with lopinavir and ritonavir.⁴⁴

MDMA is demethylated by CYP2D6, an isozyme. The protease inhibitor ritonavir is a potential inhibitor of CYP2D6. Thus, taking MDMA with ritonavir could theoretically lead to toxic effects due to a high plasma concentration of MDMA. This may be caused by this inhibition of demethylenation, the principle pathway by which MDMA is metabolized.⁴⁵

Henry and Hill describe a fatal interaction between ritonavir and MDMA in a man who had been HIV positive since 1991 and developed AIDS in 1995. In September, 1996, his regimen of zidovudine 200 mg three times a day and lamivudine 150 mg twice a day was altered to include 600 mg of ritonavir twice a day. He had taken MDMA on several occasions without problems on his prior medication regimen. He went to a club on October 6, 1996 and swallowed three tablets of MDMA. He drank beer and four hours after his arrival, he became seriously ill and died. A nurse who was attending the club described him as hypertonic, sweating, breathing rapidly, tachycardic, and cyanosed. The subject told the nurse that he had taken about 180 mg of Ecstasy. He then had a tonic-clonic convulsion. A few minutes later he vomited and had a cardiorespiratory arrest and could not be resuscitated. An autopsy was done. His lungs were edematous and congested. It was felt that the gentleman died from a severe serotoninergic reaction to Ecstasy. It is hypothesized that the ritonavir increased the level of the Ecstasy to a toxic level. The authors believe that ritonavir could react with many drugs metabolized by CYP2D6, including amphetamine derivatives, and people who use party drugs should be advised of this interaction.⁴⁵ Other researchers have noted that the effect of methamphetamines has been demonstrated to be two to three times greater for individuals on combination therapy, especially combinations including ritonavir.⁴⁶

Protease inhibitors are metabolized primarily by the hepatic cytochrome P450 system (isozyme CYP3A4) and also inhibit and induce this enzyme in varying degrees. Ritonavir also affects three other P450 cytochrome enzymes, CYP2D6, CYP2C9, and CYP2C19.⁴⁷ Three party drugs -- amphetamine, MDMA, and methamphetamine -- are metabolized by the CYP2D6 isoform of the cytochrome P450 system. Ritonavir can increase levels of these party drugs. Interestingly, ritonavir, by induction of the CYP3A4-mediated metabolism and glucuronidation of several drugs, decreased drug levels of methadone, alprazolam and meperidine hydrochloride, which are metabolized by CYP3A4. This has caused a withdrawal syndrome with these drugs.

Other drugs whose metabolic pathways are altered by protease inhibitors are benzodiazepines, opiates, marijuana, zolpidem, and Viagra. These drugs are not infrequently used with recreational drugs. The question that arises is what happens when many drugs are used together that are metabolized by the same metabolic pathway. Harrington and colleagues in Seattle believe that HIV providers should caution their patients that drug interactions between recreational drugs and medications are complex, unpredictable, and even dangerous. Some interactions are known and some are not, making this an even more serious situation.⁴⁷

Khalsa et al. believe that directions for future research should include studying the underlying mechanisms of drug interactions and metabolic pathways, interactions between illicit drugs, licit drugs, and prescription drugs. They recommend developing educational programs for clinicians to understand and treat drug interactions among drug users.⁴⁸

Adherence

Halikitis and colleagues presented an abstract at the XIV International AIDS Conference on adherence to HIV medications and club drug use among gay and bisexual men. The researchers sampled 300 gay/bisexual men; 51.9 percent missed one dose of their medicines in the two-month period prior to assessment and 47.5 percent missed one dose in the last two weeks. Based on the Abuse Screening Test, substance users/abusers reported more doses missed than nondrug users. Individuals who used club drugs were less adherent than those reporting no substance use and less adherent than those individuals who abused drugs other than club drugs. The researchers concluded that club drug use impacted adherence to HAART and needs to be addressed. They believe that this lack of adherence could be a result of the disinhibitions caused by the use of club drugs, as well as the contexts in which the substances are used.⁴⁹

This is an important observation, as other researchers have found a similar association between alcohol and drugs and adherence to HAART. Lucas et al. in a study of 764 HIV-1 infected patients found that active drug users were more likely to report nonadherence to medication and to have smaller median reductions in HIV-1 RNA from baseline and smaller median increases in CD4 counts from baseline than patients who were non-users and former drug users.⁵⁰

The data regarding adherence problems to HAART medication and alcohol and recreational drugs are not always consistent. For example, Sauders et al. studied 78 subjects with varying use of alcohol and recreational drugs (heavy users, moderate users, non-users). In this small sample they found no relationship between alcohol and recreational drug use and adherence problems. The heavy users had reported few problems with adherence but this may have been due to motivation to exaggerate actual compliance.⁵¹

Current research suggests that alcohol and drug use may affect adherence to HAART and possibly affect T cell counts and viral loads. The reasons for these effects are unclear. The reasons may relate to psychological and social problems stemming from drug use. Club drug users may have higher nonadherence rates possibly due to disinhibition of behavior caused by the recreational drugs.

Recreational drugs may also interact with antiretrovirals and with other substances, such as alcohol, Viagra, opiates, and marijuana, possibly creating a potentially dangerous and life-threatening drug combination. Club drugs may affect adherence to HAART and may have serious drug interactions with antivirals, such as ritonavir. Further study on this important topic is required.

Prevention and Harm Reduction

What is the difference between prevention and harm reduction?

Prevention programs aim to lower the rate of onset of particular disorders, such as illicit drug use in a community, by intervening when potentially harmful conditions exist.⁵² Examples of prevention programs are programs that encourage individuals not to attend raves or circuit parties to prevent exposure to the considerable drug use in these settings, programs that encourage saying no to drugs, and programs that encourage individuals not to start smoking. Harm reduction approaches, in contrast, attempt to prevent the potential harmful effects of drug use rather than preventing the drug use itself.⁵³ They are, however, compatible with prevention approaches and are in no way opposed to them. Examples of harm reduction programs are needle exchange programs and methadone maintenance.

Harm reduction is the opposite of prohibition. For instance, Great Britain responded to the health risks posed by raves by attempting to prohibit them. Rave organizers faced heavy fines and imprisonment. These measures failed because the parties moved to legitimate clubs where the dancers mixed alcohol with drugs, thereby increasing the health risks. Prior to the law, enacted by the British government prohibiting raves, only 9 percent of respondents in the 16- to 29-year-old range used Ecstasy. This rose to 91 percent among members of the dance club scene.⁹ A harm reduction approach, by contrast, could try to ensure that buildings met safety and health standards and had adequate security, and that education about health effects of the drugs was available from trained volunteers. This approach has been adopted by leaders of the rave community and by various health departments.⁹

Prevention programs are often based on the results of studies focused on the targeted communities. At other times, the prevention programs stem from members in the affected communities developing community-based programs. The following ideas come from both research and community organizations. Colfax et al. recommended the following strategies of prevention based on their research on drug use and sexual risk behavior among 295 gay/bisexual men from the San Francisco Bay area.⁴¹

1. Because one third of HIV-positive men in their study used Viagra and its use was associated with unsafe sexual practices, they suggested that physicians should reinforce safer sex messages before prescribing Viagra, and that HIV prevention programs should address potential recreational Viagra use.

2. Colfax and colleagues found that men who participated in distant city circuit parties engaged in more high-risk behaviors. The researchers believed that these men were less inhibited away from their home community rules, friends, and lovers, and recommended that health prevention programs focus on helping circuit party participants maintain safer practices both within and outside of their local communities.

3. Colfax et al. also suggest that prevention programs should educate gay/bisexual men who attend circuit parties about the risks of drug use and associated high-risk sexual behavior. They believe that prevention programs should also target HIV-positive men, who reported in their study engaging in more unprotected sex, in order to reduce the behaviors that place others at risk for HIV. This includes practicing safer sex and being open about their HIV status with their sexual partners.

Klitzman et al. also noted that MDMA users often feel it is safe to use this drug because they believe it is non-addictive.⁸ Prevention activities could include distributing facts about MDMA's toxicity, about which club or party event participants may not be aware. Halkitis et al. wrote that interventions to reduce methamphetamine use will not be effective until addiction specialists and researchers look at the underlying sexual motivations that promote the use of the drug. Since the drug is viewed as a powerful aphrodisiac that prolongs sexual enjoyment, what can gay men do to replace this drug? Is drug use worth the risks they are taking?²⁷

Harm reduction approaches accept that many individuals will probably continue to attend raves and circuit parties, and use drugs as well as continue to engage in sexual activity at these events. They hope to lessen the harm that occurs at such events by promoting safe behaviors.

Ryan and colleagues studied the relationship between substance use disorders and risk of HIV infection in gay men, and suggested the following strategy: Community-based HIV risk reduction programs need to target heavy substance users by developing active outreach programs that go into bars and clubs and have booths at raves and circuit parties to recruit participants for multi-session cognitive-behavioral intervention programs. These sessions should include strategies for reducing the use of alcohol and other drugs.⁵⁴

Weir, and Dillon and Degenhardt, suggested the following educational harm reduction messages for users of recreational drugs:^9,24

• Encourage dancers to replenish fluids and sodium (500mL/hr if dancing, 250 mL/hr if inactive).

• Take breaks from dancing.

To help recreational drug users avoid drug overdosage and illness from drug interactions, encourage patients:

• To know the risks of adulterated drugs and the inaccuracies of labels.

• To know the signs and symptoms of toxicity.

• To seek immediate medical attention if one develops signs and symptoms of drug toxicity.

• To avoid alcohol if consuming recreational drugs.

• To always eat when using GHB. Using GHB on an empty stomach causes nausea and vomiting.

• To use small doses of any drug and wait at least two hours between doses.

To advocate that organizers of raves and circuit parties are responsive to health and safety issues:

• Educate organizers about the need to have medical staff or a paramedic team on site.

• Encourage participants to insist that medical care be on site before attending an event.

• Encourage participants of raves, circuit parties and recreational drug users to care for their own health needs and to be protective of their friends:

  • Advise patients not to attend a rave or circuit party alone. Encourage patients to contract with a friend to look out for each other. (This may also help prevent date rape.)

  • Tell patients to tell their friends what they are using and to stay with them if something goes wrong.

• Advise patients that if they are taken to the hospital, not to be afraid to tell physicians and nurses what drug they used.

We would also encourage HIV-positive patients to know how party drugs will interact with Viagra and HAART to avoid life-threatening combinations.

Individuals might use drugs intravenously at circuit parties and raves. The U.S. National Institute of Drug Abuse recommends the following harm reduction strategies if individuals are not able to stop using and injecting drugs and do not want to enter and complete drug abuse treatment:

• Do not reuse or share syringes, water, or drug preparation equipment.

• Always use a new sterile syringe to prepare and inject drugs.

• Safely dispose of syringes after one use.⁵⁵

Harm reduction can result from effective role modeling by community leaders. An example of this is a harm reduction program that came out of the Mississippi Medical Center. In the early 1990s, Kelly and associates conducted harm reduction programs in three relatively small U.S. cities: Biloxi, Mississippi; Hattiesburg, Mississippi; and Monroe, Louisiana. First, they identified opinion leaders among gay men and then they trained these leaders in the social skills needed to help reduce the risk of acquiring HIV within the gay community.

In all three cities, intervention reduced high-risk behavior (unprotected anal intercourse) from 15 percent to 29 percent of baseline levels. This study illustrated that by recruiting community opinion leaders, teaching them concepts of harm reduction, and how to pass this information on to others, harmful behavior can be decreased.⁵⁶

Rave participants often have peer support groups for their parties. Some have also developed Web sites, such as raversunity.com and dancesafe.org, that have harm prevention messages. Organizations hoping to decrease harm at circuit parties might also want to determine who the opinion leaders are at these events and use these individuals to pass on safety messages and to model safer behaviors such as using condoms, not drinking alcohol along with drugs or mixing drugs, and taking breaks from dancing.

Social marketing is another method of harm reduction. Social marketing uses the elements of price, promotion, and other factors to introduce a product or behavior to the public. Social marketing of condoms is considered a key element of a global strategy to reduce AIDS. People at risk for AIDS know about condoms, but often do not use them. The Louisiana Department of Health and Hospitals' Office of Public Health hypothesized that increasing condom accessibility would increase condom use. Between 1994 and 1996, more than 33 million condoms were distributed to 93 public health clinics, 39 community mental health centers, 29 substance abuse treatment centers, and more than 1,000 businesses. An example of findings from the study show that use of condoms increased among African-American women and their partners from 28 percent in 1994 to 36 percent in 1996. Condom use increased among African-American men from 40 percent in 1994 to 54 percent in 1996.⁵⁷ Circuit parties and raves are places of heightened sexual activity. Having condoms available at these events would reduce the risk of HIV and STD transmission and would be an excellent method of harm reduction that would be low cost and effective.

Harm reduction strategies that come about from input from members of the community involved can be especially effective. Researchers from the Center for AIDS Prevention Studies at the University of California, San Francisco, developed and started an HIV prevention program in a mid-sized Oregon community, and in a similar community in Santa Barbara, California.⁵⁸ Young gay men in Eugene, Oregon, along with an advisory board made up of local community leaders, developed a program they named "The Mpowerment Project." Mpowerment taught safer sex practices through a peer-run community outreach program. The outreach activities included a publicity campaign as well as parties and social events such as bike rides and small group sessions. By using this community-based HIV harm reduction program, unprotected anal intercourse decreased from 41 percent to 30 percent in one year in the Oregon community. A peer-oriented approach to reducing recreational drug use could be developed in college communities, gay communities, circuit parties, and raves, drawing from local community members' knowledge of their peer group's beliefs, norms, and behaviors.

Harm reduction is already being instituted at some circuit parties. In 2001, in Palm Springs, California, Mayor Will Kleindienst cited concerns about drug use because of 13 overdoses at the 2001 "White Party." He had asked the City Council to consider banning the annual "White Party," which derives its name from the approximately ten thousand men who dress in mostly white clothing to attend this event. However, the city decided to allow the White Party to return to its convention center in 2002 because of the huge economic impact of the party. The organizers, to address the mayor's concerns, used harm reduction techniques and emphasized the dangers of drugs, gave out condoms, and had an ambulance waiting at the 2002 party. In 2002, there were only two overdoses at the White Party.⁵⁹

Primary prevention methods, which aim to lower the onset of behaviors that are harmful to individuals and their communities, and harm reduction, which attempts to decrease the harm created by dangerous behaviors, both play roles in preventing and decreasing the use of party drugs, in stemming the drugs' association with high-risk sexual behaviors, and in reducing rates of HIV infection at such settings as dance clubs, raves, and circuit parties. More work needs to be done in understanding what strategies are most effective and how to best apply these concepts.

Role of the Physician and Allied Healthcare Professionals

Physicians and other healthcare professionals should become more skilled at identifying alcohol and drug abuse in their practices, become more involved in educating their patients, learn how to treat medical emergencies that are club-drug related, make more use of prevention and harm reduction strategies, and become better informed about available treatment approaches for substance abusers.

1. Identifying Alcohol and Drug Abuse

Initially, one should assess a patient's current and past use of drugs and alcohol. This should cover types of substances used, routes of administration, frequency of use, age of first use, age of first regular intoxication, and the usual amount used, as well as the highest dose used. Drug and alcohol treatment history is also valuable information. Types of programs (inpatient, outpatient, methadone maintenance, Alcoholics Anonymous, residential treatment) as well as dates of treatment should be inquired about. A complete physical examination can provide evidence of alcohol and drug abuse, such as injection marks, nasal septum erosion, skin abscesses, ascites, and physical trauma.⁶⁰

Brief assessment tools such as the Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization⁶¹ and the CAGE questionnaire are helpful in identifying alcoholism, the CAGE having a 96 percent specificity for two or more positive answers.⁶² CAGE is a mnemonic for the following:

Have you ever felt you ought to Cut down drinking?

Have people Annoyed you for criticizing your drinking?

Have you ever felt Guilty about your drinking?

Have you ever had a drink first thing in the morning (Eye opener)?

Blood work can be helpful in identifying stigmata of alcohol abuse, such as elevated SGOT/SGPT, GGT, bilirubin (total), and uric acid. Alcohol is frequently mixed with club drugs in nightclubs and circuit parties. Drug screens can be performed when suspicions of drug abuse are present.

2. Education to Prevent Possible Problems

Education about the suspected role of chronic substance abuse in accelerating HIV infection and how injection drug use in particular increases overall risk, such as the risk of bacterial infections, including pneumonia and sepsis, should be undertaken. Such education should present risks for both HIV-positive and -negative drug users.^60,63

Information about club drugs and their adverse effects, in particular their role in increasing risky sexual behavior and possible medical emergencies, can be provided through handouts and brief office consultations.

3. Treating Medical Emergencies Caused by Drug and Alcohol Abuse

When adolescents and young adults present with alterations of consciousness, the physician needs to consider rave-related problems such as hyperthermia, dehydration, electrolyte imbalance, and drug overdosage. The first assessment should be the ABCs (airway-breathing-circulation) and measurement of the patient's core temperature. The level of consciousness and level of hydration need to be assessed and treated as well. Active cooling may be needed. Oral charcoal and sorbitol may be used if drug ingestion occurred within 30 to 60 minutes. Serum chemistries, liver function tests, complete blood count, creatine kinase, and arterial blood gases should be ordered. A foley catheter to prevent urinary retention should be considered. The physician should treat hypertension, tachycardia, and metabolic acidosis if present. Intensive Care Unit admission with close monitoring of blood chemistries, hepatic transaminase levels and urine output should be considered. The clinician should also be alert to the possibility that the patient was a victim of sexual assault. Finally, the doctor should be able to make referrals to drug treatment once the patient is stabilized and treated.^9,11

4. Harm Reduction

The U.S. National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends that healthy men limit their drinking to 14 drinks per week and that women limit it to seven. Men who consume an average of more than two drinks per day have higher incidences of hypertension and cancers, with problems for women beginning above an average of one drink per day.⁶⁴ Limiting alcohol use to social drinking levels may be helpful in reducing harm when not mixed with club drugs. Alcohol can interact with other party drugs in harmful and unpredictable ways, and the patient who intends to use club drugs in spite of the risks would be advised not to drink alcohol at all.

Ways in which club drug users can reduce their risk of HIV/AIDS include:

• Stopping the use and injection of club drugs.

• Using only sterile syringes if the patient continues to inject drugs.

• Using only sterile supplies and never sharing if injecting drugs continues.⁵⁵

The physician may have HIV/AIDS patients who intend to continue to use club drugs in spite of the risks involved in drug interactions with their HAART regimen. In such cases, the physician can select antivirals that interact minimally with club drugs. For example, ritonavir should be avoided by patients who regularly use MDMA.

In some instances, community interventions that have successfully reduced high-risk sexual behavior from baseline levels utilized popular peers within a community to encourage such behaviors as:

• Keeping condoms nearby if sexually active.

• Avoiding sex when intoxicated.

• Assertively refusing unsafe sex coercions. ⁵⁶

5. Treatment Strategies

Education, prevention, and harm reduction are more appropriate strategies than a treatment focus for the occasional club drug user. When patients meet criteria for alcohol or drug dependency, consider:

• Alcohol- and drug-dependent patients may benefit from a brief hospitalization to detoxify when they meet criteria for substance dependency.

• In treating alcohol dependency, naltrexone (ReVia), particularly in combination with coping skills therapy, can be effective in reducing craving.⁶⁵ Disulfiram (Antabuse) can also be helpful in motivating the alcoholic not to drink.⁶⁰

• Treating underlying psychiatric conditions, such as clinical depression and anxiety disorders, with non-addictive medications such as SSRIs, or referring to a psychiatrist when screening has been positive for psychiatric disorders, is advisable. Referrals to a psychologist specializing in dual diagnoses (substance abuse and psychiatric disorders) for outpatient psychotherapy may also be appropriate.

• Support groups such as Alcoholics Anonymous and Narcotics Anonymous have been correlated with successful outcomes in a large-scale study⁶⁶ and can be recommended for many.

• No single treatment is appropriate for all individuals, and intervention needs to be matched to the individual's problems.⁵⁵

• One effective treatment is a cognitive-behavioral therapy known as relapse prevention. Relapse prevention focuses on the identification of the individual's high-risk situations for alcohol and drug abuse and on learning coping strategies that can take the place of the substances.^67,68

• The physician or allied healthcare professional can increase his or her skills to motivate the substance abuser to seek out help by learning motivational interviewing skills.^69,70

• Additional information can be gathered from www.drugabuse.gov, and www.clubdrugs.org.

• Other Web sites of interest for harm reduction messages are: www.raversunity.com and www.dancesafe.org.

By utilizing some of the above approaches, physicians and other healthcare professionals can better assess and counsel the patient who is using or is considering using club drugs as part of their recreational activities.

Conclusions

Much evidence is available to support the association between club drugs and high-risk sexual behaviors. Documentation showing how such behavior leads, in turn, to higher rates of HIV infection is available almost exclusively for the gay and bisexual community. Not much is known about the high-risk sexual behaviors associated with club drug use among the largely heterosexual ravers. Club drugs themselves have other serious medical consequences for their users, gay or heterosexual, and are particularly dangerous for the HIV/AIDS patient on HAART because of possible drug interactions and adherence problems. Prevention and harm reduction approaches can be helpful in protecting persons thinking of or engaging in club drug use. Physicians and other healthcare professionals can play a role in assessing, supporting, and counseling the at-risk patient by providing education and options even when the patient is not inclined to make the same choices that the professional would have made.

Alan Cooper has a private practice of clinical psychology in Arlington, Garland, and Rockwall, Texas, as an associate of The Lakewood Group. Jan Swanson has a private practice of internal medicine in Arlington, Texas. Cooper and Swanson are coauthors of The Complete Relapse Prevention Skills Program published by Hazelden Educational Materials.

References

1. Drug Enforcement Administration. An overview of club drugs. Drug Enforcement Administration February 2000:1-10.

2. Rhodes F., Deren S., Wood M.M., Shedlin M.G. et al. Understanding HIV risks of chronic drug-using men who have sex with men. AIDS Care 1999;11:629-648.

3. Doherty M.C., Garfein R.S., Monterroso E. et al. Correlates of HIV infections among young short-term injection drug users. AIDS 2000;14:717-726.

4. Blumenthal R.N., Kral A.H., Gee L., Lorvick J. et al. Trends in HIV seroprevalence and risk among gay and bisexual men who inject drugs in San Francisco, 1998 to 2000. JAIDS 2001;28264-269.

5. Strathdee S.A. et al. Sex differences in risk factors for HIV seroconversion among injection drug users. Arch Internal Med 2001;161: 1281-1288.

6. Leshner, A.I. A club drug alert. NIDA Notes 2000;14:3-4.

7. Stall R., Paul J.P., Greenwood G., Pollack L.M., et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: The Urban Men's Health Study. Addiction 2001;96:1589-1601.

8. Klitzman R.L., Greenberg J.D., Pollack L.M., Dolezal C. MDMA ("Ecstasy") use, and its association with high-risk behaviors, mental health, and other factors among gay/bisexual men in New York City. Alcohol and Drug Dependence 2002;66:115-125.

9. Weir E. Raves: A review of the culture, the drugs and the prevention of harm. Canadian Medical Association Journal 2000;162:1843-1848.

10. Tong T., Boyer E.W. Club drugs, smart drugs, raves, and circuit parties: An overview of the club scene. Pediatric Emergency Care 2002;18: 216-218.

11. Rieder M.J. Some light from the heat: Implications of rave parties for clinicians. Canadian Medical Association Journal 2000;162:1829-1830.

12. Guzman R. Circuit parties. Focus March 2001:4-6.

13. Mansergh G., Colfax G.N., Marks G. et al. The Circuit Party Men's Health Survey: Findings and implications for gay and bisexual men. American J Public Health 2001;91:953-958.

14. Klitzman R.L., Pope H.G., Hudson J.I. MDMA ("Ecstasy") abuse and high-risk sexual behaviors among 169 gay and bisexual men. Am J Psychiatry 2000;157:1162-1164.

15. Holcomb R. Personal Communication. August 2002.

16. Office of National Drug Control Policy. Club drugs. Source: www.whitehousedrugpolicy.gov/drugfact/club/index.html; May 2002.

17. Webb E., Ashton C.H., Kamali F. Alcohol and drug misuse in UK university students. Lancet 1996;348:922-925.

18. Winstock A.R., Griffiths P., Stewart D. Drugs and the dance music scene: A survey of current drug use patterns among a sample of dance music enthusiasts in the UK. Drug and Alcohol Dependence 2001;64:9-17.

19. National Institute of Drug Abuse. Club drugs. Community Drug Alert Bulletin. Source: http://165.112.78.61/ClubAlert/ClubdrugAlert.html. 2002.

20. Mathias R., Zickler P. NIDA conference highlights scientific findings on MDMA/Ecstasy. NIDA Notes 2001;16:1-12.

21. Henry J.A., Jeffreys K.J., Dawling S. Toxicity and deaths from 3,4-methylenedioxymethamphetamine ("Ecstasy"). Lancet 1992;340:384-387.

22. Mathias R. The many faces of MDMA use challenge drug abuse prevention. NIDA Notes December 2001;16:9-14.

23. Whitten L. Conference highlights increasing GHB abuse. NIDA Notes May 2001;16:10-11.

24. Dillon P., Degenhardt L. Ketamine and GHB: New trends in club drug use? J Substance Abuse 2001;6:11-15.

25. Zickler P. NIDA launches initiative to combat club drugs. NIDA Notes March 2000;14:1-5.

26. Jansen K.L.R. Ketamine, Dreams, and Realities. Florida: Multidisciplinary Association for Psychedelic Studies; 2000.

27. Halkitis P.N., Parsons J.T., Stirratt M.J. A double epidemic: Crystal methamphetamine drug use in relation to HIV transmission among gay men. J Homosexuality 2001;41:17-35.

28. Reback C.J. The social construction of a gay drug: Methamphetamine use among gay and bisexual males in Los Angeles. Report funded by the city of Los Angeles (Contract#93427) 1997.

29. Kim A.A., Kent C.K., Klausner J.D. Increased risk of HIV and sexually transmitted disease transmission among gay or bisexual men who use Viagra, San Francisco 2000-2001. AIDS 2002;16:1425-1428.

30. Aldridge J., Measham F. Sildenafil (Viagra) is used as a recreational drug in England. British Med J 1999;318:669.

31. Crosby G.M., Stall R., Paul J.P., Barrett D.C., Midanik L.T. Condom use among gay/bisexual male substance abusers using the timeline follow-back method. Addictive Behaviors 1996;21:249-257.

32. Dolezal C., Meyer-Bahlburg H.F.L., Remien R.H., Petkova E. Substance use during sex and sensation seeking as predictors of sexual risk behavior among HIV+ and HIV- men. AIDS and Behavior 1997;1:19-28.

33. Van de Ven P., Campbell D., Kippax, S. et al. Factors associated with unprotected anal intercourse in gay men's casual partnerships in Sydney, Australia. AIDS Care 1997;9:637-649.

34. Paul J.P., Stall R., Davis F. Sexual risk for HIV transmission among gay/bisexual men in substance abuse treatment. AIDS Education and Prevention 1993;5:11-24.

35. Catania J.A., Coates T.J., Kegeles S., et al. Condom use in multi-ethnic neighborhoods of San Francisco: The population-based AMEN (AIDS in Multi-Ethnic Neighborhoods) study. American J Public Health 1992;82:284-287.

36. Vittinghoff E., Buchbinder S.P., Judson F., McKiman D., MacQueen K. Per-contact risk of HIV associated with four types of homosexual contact. Paper presented at the Fifth Annual Conference of Retroviruses and Opportunistic Infections. Chicago, IL 1998.

37. Shoptaw S., Reback C.J., Frosch D.L., Rawson R.A. Stimulant abuse treatment and HIV prevention. J Addictive Diseases 1998;17:19-32.

38. Dolezal C., Carballo-Dieguez A., Nieves-Rosa L., Diaz F. Substance use and sexual risk behavior: Understanding their association among four ethnic groups of Latino men who have sex with men. J Subst Abuse 2000;11:323-336.

39. Ostrow D.G., Beltran E.D., Joseph J.G., et al. Recreational drugs and sexual behavior in the Chicago MACS/CCS cohort of homosexually active men. J Subst Abuse 1993;5:311-325.

40. Chaisson J., Stoneburner R., Hildebrandt D., et al. Heterosexual transmission of HIV-1 associated with the use of smokable freebase cocaine (crack). AIDS 1991;5:1121-1126.

41. Colfax G.N., Mansergh G., Guzman R., Vittinghoff E., et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: A venue-based comparison. JAIDS 2001;28:373-379.

42. Mattison A.M., Ross M.W., Wolfson T., Franklin D. HNRC group circuit party attendance, club drug use, and unsafe sex in gay men. J Subst Abuse 2001;13:119-126.

43. Chesney M.A., Barrett D.C., Stall R. Histories of substance abuse and risk behavior: Precursors to HIV seroconversion in homosexual men. American J Public Health 1998;88:113-116.

44. Pau A.K. Polypharmacy problems: Drug interactions in the multidrug therapy of HIV infection. Source: www.hiv-druginteractions.org. January 2002.

45. Henry J.S., Hill I.R. Fatal interaction between ritonavir and MDMA. Lancet 1998;352:1751-1752.

46. Horn G. Party favors. Poz 1998:90.

47. Harrington R.D., Woodward J., Hooton T.M., Horn J.R. Life-threatening interactions between HIV-1 protease inhibitors and the illicit drugs MDMA and gamma-hydroxybutyrate. Arch Intern Med 1999;159: 2221-2224.

48. Khalsa J., Genser S., Vocci F., Francis H., Bean P. The challenging interactions between antiretroviral agents and addiction drugs. American Clinical Laboratory April 2002:10-13.

49. Halkitis P.N., Kutnick A.H., Borkowski T., Parsons J.T. Adherence to HIV medications and club drug use among gay and bisexual men. 2002 XIV International AIDS Conference 2002.

50. Lucas G.M., Cheever L.W., Chaisson R.E., Moore R.D. Detrimental effects of continued illicit drug use on the treatment of HIV-1 infection. JAIDS 2001;27:251-259.

51. Saunders D.S., Lancee W.J., Rourke S.B. The effect of alcohol and drug use on HAART adherence. Source: www.pulsus.com/cahr/abs/abs222.htm. Oral presentation. 2001.

52. Freedman A.M., Kaplan H.I., Sadock B.J. Modern Synopsis of Psychiatry. Baltimore: The Williams and Wilkins Co., 1972.

53. Duncan D.F., Nicholson T., Clifford P., Hawkins W., Petosa R. Harm reduction: An emerging new paradigm for drug education. J Drug Education 1994;24:281-290.

54. Ryan C.M., Huggins J., Beatty R. Substance use disorders and the risk of HIV infection in gay men. J Stud Alcohol 1999;60:70-77.

55. National Institute of Drug Abuse. Principles of HIV prevention in drug-using populations. NIH Publication No. 02-4733:2002;1-32.

56. Kelly J.A., St. Lawrence J.S., Diaz Y., et al. HIV risk reduction following intervention with key opinion leaders of population: An experimental analysis. American J Public Health 1991;81:168-171.

57. Cohen D.A., Farley T.A., Bedimo-Etame J.R., et al. Implementation of condom social marketing in Louisiana, 1993 to 1996. American J Public Health 1999;89:204-208.

58. Kegeles S.M., Hays R.B., Coates T.J. The Mpowerment project: A community-level HIV prevention intervention for young gay men. American J Public Health 1996;86:1129-1136.

59. Leinwand D. Worries crash "circuit parties." USA Today June 20, 2002.

60. Hsu J.H. Substance abuse and HIV. The Hopkins HIV Report July 2002:1-11.

61. Babor T.F., Grant M. From clinical research to secondary prevention: International collaboration in the development of the Alcohol Use Disorders Identification Test (AUDIT). Alcohol Health and Research World 1989;13:371-374.

62. Bradley K.A., Boyd-Wickizer J., Powell S.H., Burman M.L. Alcohol screening questionnaires in women. JAMA 1998;280:166-171.

63. Selwyn P.A., Alcabes P., Hartel D., et al. Clinical manifestations and predictors of disease progression in drug users with human immunodeficiency infection. New Eng J Med 1992;327:1697-1703.

64. National Institute on Alcohol Abuse and Alcoholism. The Physician's Guide to Helping Patients With Alcohol Problems. Bethesda, MD: 1995, NIH Publication No. 95-3769.

65. Garbutt J.C., West S.L., Carey T.S., et al. Pharmacological treatment of alcohol dependency: A review of the evidence. JAMA 1999; 281:1318.

66. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH post-treatment drinking outcomes. J Stud Alcohol 1997;58:7-29.

67. Marlatt G.A., Gordon J.R. Relapse Prevention: Maintenance Strategies in the Treatment of Addiction Behaviors. New York: The Guilford Press, 1985.

68. Swanson J., Cooper A. The role of alcohol and drug relapse prevention in the treatment and prevention of HIV disease. J Int Assoc Phys AIDS Care 1998.

69. Rollnick S., Bell A. Brief motivational interviewing for use by the nonspecialist. In Miller W.R., Rollnick S. (Eds.) Motivational Interviewing. New York, NY: The Guilford Press, 1991.

70. Baker A., Dixon J. Motivational interviewing for HIV risk reduction. In Miller W.R., Rollnick S. (Eds.) Motivational Interviewing. New York, NY: The Guilford Press, 1991.

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