Journal of Student Research (2013)
Volume 2, Issue 1: pp.
17-21
Research Article
a. Willamette University, Salem, OR, 97301
www.jofsr.
com
17
Amyl Nitrites: A Review of History, Epidemiology, and
Behavioral Usage
David Cheng
This paper looked into the abuse of inhalable nitrites, mainly amyl nitrites, commonly known by the street name of poppers.
This
paper compiled several studies of nitrite inhalant abuse and the risk associated with the sexual practices that may concur.
The
paper explores first, the history and true intentions of nitrite inhalants, then the increasing abuse mainly within the homosexual
community, and the legitimacy of the link of nitrites and the HIV/AIDS epidemic.
Various studies discussed in the paper will
show that there is no legitimate link between poppers increasing the chance of HIV/AIDS but it is the unsafe sexual practices that
occur with poppers that lead to various sexually transmitted diseases.
The dangers of inhalable nitrites come from legal
loopholes, use with other drugs such as Viagra, and the nature of unsafe sexual practices mostly within the homosexual
community.
Keywords: Drugs; Inhalants; Sex; Homosexual
BASIC FACTS OF AMYL NITRITES
C
5
H
11
ONO is the chemical formula of amyl nitrite; there
are several isomers but they all feature amyl groups with a
nitrite group attached.
Amyl nitrites falls into a group of drugs
which is more commonly known by the street name
‘poppers’.
Popper is a slang term to describe the various alkyl
nitrites such as isopropyl nitrite, isobutyl nitrite, butyl and
amyl nitrites inhaled for recreational purposes.
Unlike most
other inhalants the effects of poppers don’t last very long and
don’t create the same ‘high’ as other inhalants (Meyer, 2005).
The name popper comes from the sound of the small glass
ampoules that were crushed to release the inhalants.
The
substance itself is a clear, yellowish liquid that has a peculiar
ethereal, fruity odor and is highly volatile (“Data sheet: Amyl
nitrite,” 2000).
All of these compounds are based upon the
chemical structure R-ONO.
The most commonly used
products for abuse are air freshener, video head cleaner, and
finger nail polish remover.
Nitrites relax smooth muscle tissue
such as the anus, iris and dilate blood vessels which cause a
drop in blood pressure (Cohen, 1979).
Poppers are almost
always inhaled for recreational use producing a sense of
warmth, mild euphoria, and sometimes visual distortions
(Kuhn, 2003).
Often the intention of popper users is to
increase sexual pleasure often among the homosexual
population due to the smooth muscle relaxation effects of the
drug. As will be seen, poppers have been the subject of
several studies attempting to link nitrite abuse with sexual
behavior (Colfax, 2001; Haverkos, 1988; Kennedy, 1988).
The medically intended uses of nitrites was to relieve heart
pain by dilating arteries allowing more blood flow to the heart
and as an antidote to cyanide poisoning by producing
methemoglobin in the blood stream which binds to and
neutralizes the cyanide.
HISTORY
The drug is popular among the club and rave scene and
nitrites as a chemical compound has been around since
the 1850s.
Amyl nitrite was originally created by Antoine
Jerome Balard, a French chemist known for the discovery of
bromine.
However it was not until the late 1850s that Sir
Thomas Lauder Brunton used amyl nitrite as a treatment for
angina pectoris (chest pain).
Doctors discovered that amyl
nitrites helped to relax smooth muscle allowing increased
blood flow to reach the chest.
It was particularly effective in
the treatment of heart and chest pain.
However, doctors
noticed that the drug was unreliable at times with the effects
disappearing too rapidly to have any long term health
benefits.
Amyl nitrite is still inhaled however when rapid
absorption is required for some heart problems.
It was also
found that amyl nitrites was an effective cyanide poising
antidote and EMTs today still carry amyl nitrite antidote kits.
In 1960, the FDA approved nitrites as an over the counter
drug without the need for a prescription.
One short year later,
the FDA instated a prescription requirement and only amyl
nitrites were approved for use in humans.
The popper craze
began in the 1970s and by 1979; over 5 million people in the
United States used poppers more than once a week (Haverkos,
1988).
Academic research into nitrites began in the 1970s
with mixed conclusions over the correlation of AIDs, HIV,
and Karposi’s sarcoma and abuse of inhaled nitrites.
Politically in the United States, politicians in Washington
were advised over the years that nitrite inhalation posed no
significant risk and that no further federal action was needed
(Kennedy, 1987).
Despite this, lawmakers banned the sale of
nitrites for human consumption.
Illicit use began with
adolescents in 1960 that purchased nitrites as recreational
inhalants.
Popper abuse really began to take off in the 1970s
as the disco club scene began to take over.
TIME magazine
reported that popper abuse (legal at the time) was a
fabrication of the homosexual population as a way to enhance
sex (Nation: Rushing to a New High, 1978).
Poppers quickly
spread to heterosexual couples and continued into the rave
and club scenes of the future.
Poppers contain nitrites that are
synthesized from alcohols and sodium nitrite in a solution of
sulfuric acid.
The solution is mixed and decomposes slowly at
room temperature and is bottled into small ampules for use.
Journal of Student Research (2013)
Volume 2, Issue 1: pp.
17-21
Research Article
ISSN: 2167-1907
www.jofsr.
com
18
EPIDEMIOLOGY
The Monitoring the Future Survey found that through
2007 to 2010 among 8th, 10th, and 12
th
graders, lifetime use
of inhalants is on the decline.
However, short term month to
month use appears to be on the rise; from 2007 to 2008 use
rose from 2.
1 percent to 2.
2 percent among 10th graders.
Also
past year use appears to be increasing among all three grade
levels (Monitoring the Future, 2010).
The National Survey on
Drug Abuse and Health also shows that the majority of users
are adolescents between the ages of 12 – 17 and about 67
percent of users where less than 18 when they first used
inhalants.
(Substance Abuse & Mental Health Services
Administration, 2011).
Below is a chart from the National
Survey of Drugs and Health showing specific types of
inhalants abused by users aged 12 to 17 from 2002 to 2007.
A
1988 study found that 69% of men who had sex with other
men in the Baltimore/DC area used poppers (Lange, 1988).
When compared to other abused drugs, a more recent report
of 736 homosexual men in San Francisco, found poppers to
be the most widely abused substance when compared to
cocaine and methamphetamines (Colfax, 2005).
Although
dated, it is positive to see a 1987 survey commissioned by the
US Senate that found only 3% of Americans had even used
poppers (Kennedy, 1987).
Also interesting, about 20% of the
teenage population in the United Kingdom (UK) abuses
nitrites due to it being legal in the UK.
Nitrite abuse among
users was more frequently reported among the white
population relative to blacks or Hispanics and more often
abused by men than women (Haverkos, 1988).
Although amyl
nitrite abuse isn’t has high as other inhalants it still poses an
inherent risk to abusers and data indicates that nitrite abuse is
on the rise.
This may be caused by a perception that inhalants
aren’t as dangerous as other types of drugs such as cocaine or
heroin.
PHYSIOLOGICAL IMPACT
Like many inhalants, the route of administration is nasal.
The inhaled nitrites quickly reach the lungs and diffuse
through the pulmonary alveoli and into the capillaries full of
oxygen rich blood on its way to the heart.
The heart then
quickly distributes the nitrites to tissues in the body allowing
an effect to be felt quickly.
Average times for the onset of
effects are about thirty seconds and the effects last anywhere
from three to five minutes (Wolters Kluwers Health, 2009).
Not enough research has been done to confirm the
metabolism but it is believed that nitrites are metabolized by
hydrolytic denitration and about a third of the drug is excreted
through
urine
(Baxter
Healthcare,
2000).
The
pharmacodynamics are not known for sure but the acute
effects of volatile inhalants like nitrites often produce effects
similar to alcohol intoxication (Meyer& Quenzner,2005).
The
effects are very consistent and users can expect headaches,
flushing of the skin, dizziness, weakness, and in very high
does can cause anesthesia, loss of consciousness and even
comas (Kuhn, 2003).
Users report that they get a feeling of
warmth, pounding hearts, and a loss of inhibitions.
The ocular
organs also have increased intraocular pressure and
supraorbital pain.
Inhaled nitrites also appear to be able to
interact with endogenous trivalent nitrogen compounds that
produce nitrosamines that are known to be carcinogens
(Haverkos, 1988).
It is widely believed that there is a correlation between
nitrite abuse and AIDS/HIV however there are multiple
studies that suggested there is no correlation between the two
(Kennedy, 1988).
Amyl nitrites are abused mainly for their
muscle relaxing effects for easier anal and vaginal sex.
Users
claim that poppers help prolong erections and increase libido.
The real value is the effect of the “relaxation of rectal smooth
muscle and anal sphincter tone, thus facilitating intromission”
(Haverkos, 1988).
In other words the relaxation of the anus
helps reduce the pain and increase the ease of penetration.
Haverkos (1988) also states that the illicit usefulness of amyl
nitrites has allowed it to pass into every corner of gay life.
The issues of poppers are that when they are abused for sex,
questionable and unsafe sexual behavior can occur and many
believe poppers are a contributing factor towards the
Acquired Immunodeficiency Syndrome (AIDS) and Human
Immunodeficiency Virus (HIV) epidemic.
According to
Colfax (2001), amyl nitrite abuse is the third highest risk
indicator of having unprotected anal sex behind Viagra and
crystal meth.
This is significant considering the ease of
availability of poppers that can be purchased online with just
a credit card.
According to Schwarcz (2007), a study
conducted on homosexual and bisexual men in San Francisco
found that 29.
1 percent of HIV positive men used amyl
nitrites.
It is interesting to note that the same study showed
that 87.
2 percent of HIV positive and 78.
9 percent of HIV
negative men had intercourse with a male compared to only
2.3 and 9.
6 percent of the HIV positive and negative groups
saying they had intercourse with a female.
Based off of this
data, it could be concluded that amyl nitrite abuse is most
common among the homo and bisexual male population.
The
only drug that was used more than amyl nitrites in the
Schwarcz (2007) study was Viagra and that remained constant
in both the HIV positive and negative community.
The
Schwarcz (2007) study found that 44.
2 and 22.
4 percent of the
HIV positive and negative groups used Viagra and because
amyl nitrites are the most used drug after Viagra, this can be
alarming.
Amyl nitrites are contraindicative with other
vasodilators like Viagra and, when used in combination, can
cause a serious decrease in blood pressure that can lead to
fainting, strokes, and heart attacks.
The link between Viagra
use and popper use could be because the side effects of amyl
nitrites can cause erectile problems prompting the use of
Viagra.
Haverkos (1998) also found that individuals that used
poppers frequently had almost two times more partners a
week than those who never used nitrites.
Occasional users had
about one and a half times more partners than those who
never used.
Nutt (2007) suggests that nitrites as a group have the
second least addictive potential and is the third least harmful
among the twenty most commonly abused drugs.
Despite this,
there are still a variety of other health problems associated
with nitrites that are particularly dangerous.
Only amyl nitrite
is produced for legitimate medical use in humans and is
approved by the FDA.
This means other nitrites commonly
found in poppers such as butyl nitrite and akyl nitrites are
industrial chemicals and could be harmful.
The major
problem is when nitrites are swallowed instead of inhaled.
By
ingesting nitrites, a person runs the risk of
methemoglobinemia, a condition in which the nitrites
Journal of Student Research (2013)
Volume 2, Issue 1: pp.
17-21
Research Article
ISSN: 2167-1907
www.jofsr.
com
19
interfere with the way oxygen bonds with hemoglobin in the
blood.
Ingesting nitrites has the similar effects of cyanide
poising but to a slower degree.
Awareness of the negative
effects of nitrite abuse was being raised in the early 1970s
because of the growing concern over AIDs.
The belief that
nitrite inhalation was a factor in AIDs was well warranted as
the first five homosexual men with AIDs that were reported to
the Centers for Disease and Control (CDC) all abused nitrite
inhalants (Centers for Disease and Control, 1981).
Another risk that was believed was an effect of poppers
early in the AIDS epidemic was the development of Kaposi’s
sarcoma.
Kaposi’s sarcoma is a kind of skin cancer that is one
of the most common symptoms of AIDs.
It was also another
public perception that poppers were the cause of Kaposi’s
sarcoma however several subsequent research into the matter
showed that it was the sexual “actions” that were responsible
for obtaining the AIDs related skin cancer (Beral, 1992).
Actions such as fisting and rimming are thought to be the
main causes and that the faecal-oral contact are the main
routes of transmission of Kaposi’s sarcoma in homosexual
and bisexual men with AIDs.
It could be said that the poppers
ability to relax the anus can be blamed for some the actions
that could be associated with Kaposi’s sarcoma and the sexual
behavior associated with Kaposi’s sarcoma but Beral (1992)
claims the cases of Kaposi’s sarcoma was somewhat rare
prior to the outbreak of AIDs, suggesting that AIDs is the
main factor.
Another study also theorized that a history of
Syphilis, not the use of poppers, was the underlying cause for
Kaposi’s sarcoma.
Haverkos (1988) compiled data showing
that patients with a history of Syphilis are two times more
likely to contract Kaposi’s sarcoma.
An idea that has been presented about the association
between HIV/AIDS and nitrite usage is that nitrites suppress
the immune system.
A study done on eighteen male
volunteers found that nitrite inhalation did indeed suppress the
immune system.
The number of T - lymphocytes, the site of
attack of HIV and AIDs, temporarily decreased (but not to a
dangerous degree) during inhalation and returned to normal
levels after about a week (Dax, 1991).
Nitrite inhalation
causes a little more vulnerability to HIV and AIDs as
suggested by the investigation but there is not a significant
long term risk unless the drug is heavily abused.
It is
conceivable that popper users could use them several times
over the course of a day or weekend which makes it a very
interesting suggestion of how HIV and AIDs could spread.
However, this is really only limited to the sexually active
population with access to the drug which is mainly in
industrialized Western countries.
There has also been concern over possible eye damage in
habitual popper users.
In a report of six patients who abused
poppers, doctors noted that all patients experienced
progressive bilateral vision loss (Audo, 2011).
Doctors
believed that the repeated use of poppers causes vision loss
due to disruption of the foveal cone but also suggested that
the damage may heal itself if popper use is stopped.
Some
other side effects include burns if the nitrites are spilled on
skin and can cause lipoid pneumonia if accidently swallowed
into the lungs.
Lipoid pneumonia is when oils enters into, and
inflames, the lungs.
Users can develop a tolerance to the drug and there are
symptoms from withdrawal.
The most common problems
with withdrawal are cardiac and circulatory problems and
patients are usually prescribed nitroglycerin patches (Kuhn,
2003).
The issue is the tolerance that has been built up by use
of poppers that reduce the effectiveness of nitroglycerin
patches and the cardiac problems that accompany with this.
Another health issue is a possibility of cancer.
Inhaling
nitrites interact with endogenous trivalent nitrogen
compounds to produce nitrosamines.
Nitrosamines are well
established carcinogens in animal studies with increased
nitrites in diets leading to liver cancer (Newell,1985).
Although no direct studies on humans have been conducted, it
is thought that nitrosamines can cause gastric cancer (Hill,
1973).
Although there may be evidence linking nitrite
inhalants and cancer, one would probably have to be a
habitual user of nitrite inhalants to significantly increase the
chance of cancer.
LEGALITY
It is important to discuss the legal aspects of poppers
because of the unique situation of being a medically approved
product but also an industrial chemical agent.
Amyl nitrite
requires a prescription after wide spread abuse in the 1960s.
Other nitrites such as alkyl nitrites were banned by the United
States in the Anti – Drug Abuse Act of 1988.
Interestingly,
the law was only for human consumption and granted an
exception for products with commercial purpose.
Basically,
this means that as long as a manufacturer claims the product
is not intended for human consumption, it is legal.
This
allows poppers to be legally sold, usually in sex shops, as
video head cleaner, polish remover, and room air refreshers as
industrial products intended for uses other than human
consumption.
It is easy to see however that these products are
truly intended for human consumption and what is more
ironic is that they are not regulated by the FDA because,
technically, this is an industrial product.
This legal loophole,
although beneficial to manufactures, can be harmful to the
consumer because of unregulated production practices.
By
claiming nitrite poppers are deodorizers and video head
cleaners, this completely bypasses the safety tests that each
drug must go through in order to be sold to the population.
It
is also incredibly ironic that labels warning against the
dangers of inhalation are on the ampules of poppers such as
Rush, however the intention is for the nitrite to be inhaled.
In
the early 1990s, most Western nations outlawed the sale and
importation of alkyl nitrites for inhalant uses.
Poppers
however remain legal in many countries like the United
Kingdom and China and are easily purchased by adolescents.
CONCLUSION
In conclusion, nitrite poppers are most often used in the
homosexual male population for sexual pleasure.
However,
there should be done more to control the use and sale of
poppers.
It can be argued that nitrites should be banned due to
its role in the AIDs and HIV epidemic.
But this is only
because of the unsafe sex practiced under the influence of
poppers.
Studies such as Kennedy (1988) have found no link
between HIV/AIDS and popper use.
However, it is uncertain
if there is correlation or causal relation between popper use
and HIV/AIDS due to numerous underlying factors and the
difficulty of conducting a true experiment.
No studies also
have been conducted on the long term health effects of
Journal of Student Research (2013)
Volume 2, Issue 1: pp.
17-21
Research Article
ISSN: 2167-1907
www.jofsr.
com
20
repeated popper abuse either.
Also, nitrite inhalants do not
significantly decrease immune function enough to contract
HIV/AIDS commonly (Dax, 1991).
The immune systems
studied also returned to normal health fairly quickly so there
isn’t a long term immune function decrease.
The effect of
poppers on sexual behavior is very large especially in the
homosexual community.
The health risks associated with
poppers cannot be denied as diseases such as Kaposi’s
sarcoma and AIDS are much more common among
homosexual populations and unsafe sex practices are to
blame.
Poppers do not necessarily lead to sexually transmitted
disease but it is the unsafe sex practices stemming from
popper use.
More sex education should be provided to the
population detailing the dangers of poppers and ways to
safely use them.
Further the legal loophole that allows for
inhalable nitrites to exist without medical prescription needs
to be closed.
If the loophole is not addressed then nitrite
inhalants should be classified as a drug and undergo the safety
testing that they currently avoid by being labeled as
deodorizers.
Amyl nitrites should only be used for its
medically intended functions, not for its purposes in the
homosexual universe.
ACKNOWLEDGEMENTS
The author wishes to express sincere appreciation to
Willamette University, the psychology department for their
support, and especially to Professor Brian J.
Piper for his
patience and knowledge.
An earlier version of this review was
completed as part of a course, Neuropharmacology and
Behavior, by Brian J.
Piper, PhD.
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