by ERIC ERICKSON

Mixing the blue pill with the little brown bottle can be lethal.

It can also be exhilarating.

That’s why the mixture of Viagra and poppers, two legal drugs -- though one requires a prescription, is gaining popularity among gay men.

And now, some health officials are sounding an alarm: On Monday, a Board of Supervisors panel in San Francisco discussed an ordinance requiring businesses that sell poppers to post warning signs about possible dangers of using the nitrate-based liquid as a drug.

If approved by the Board of Supervisors, it would mark a return to enforcement of an ordinance on the books since the 1980s that calls for misdemeanor penalties for any business that did not post the warnings.

Other health officials and AIDS experts also warn that using the drugs -- individually or in combination -- can lead to an increase in risky sex at a time when HIV and other sexually transmitted diseases are making a resurgence among gay men.

"I have heard about a number of disturbing incidences where guys have used [Viagra and poppers] at the same time," said former New York City resident Steve Bolerjack, a gay columnist and frequent contributor to the Blade. "I think that the fact that they're doing it is a reflection of an attitude that is very prevalent among gay men. Why do they use recreational drugs? Why do they combine GHB and alcohol sometimes? Why do guys die on the dance floor from doing recreational drugs? It's the kind of mentality that says, 'It can't happen to me,' or 'I'll only try it this once.'"

The drugs

Viagra, a prescription drug used to offset erectile dysfunction, is quickly gaining the reputation as a popular club drug, allowing men to have longer sexual experiences when other substances render them temporarily impotent.

Many gay men use Viagra for its intended purpose: an answer for persistent erectile dysfunction.

Also seeing an increase in use are amyl nitrates, known socially as "poppers," which some men use to heighten their sexual experiences by relaxing their bodies after inhaling.

Some warn that using poppers and Viagra simultaneously can lead to dangerously low blood pressure, stroke, heart attack or possibly death.

"The use of Viagra and poppers is a very dangerous thing," said Marty Algaze, spokesperson for Gay Men's Health Crisis in New York City. "I've heard anectodal stories of people who have had real problems and who have died."

He added, "Mixing things with Viagra -- unless the doctor says it's OK -- you should not do, especially poppers."

Poppers, liquid amyl nitrate or butyl nitrate found in small brown bottles, are often sold under the guise of video head cleaner and can be found at gay novelty stores, bars, adult video stores, bath houses and on the Internet.

The San Francisco Public Health & Environment Committee, a panel of the Board of Supervisors, is considering reviving the health warnings about poppers to help educate people, said Tom Ammiano, the gay president of the Board of Supervisors.

"To me, it seems reasonable," Ammiano said. "There could be a possible risk, so you would have an informed consumer."

The ordinance requiring businesses to post such warnings about poppers has been on the books since 1983, but has rarely, if ever, been enforced.

After hearing from local public health officials, Ammiano said the committee decided to make a recommendation to the full Board "calling for the formation of a work group made up of the District Attorney’s office and the Department of Public Health to see what it would take to reinstitute the program."

Ammiano said the panel has received verbal support from owners of local bath houses and sex clubs, where poppers are commonly used.

Knowing the risk

The combination of Viagra and poppers is dangerous because the two drugs affect the human body in about the same way, lowering a person’s blood pressure, according to Dr. Jeffrey Klausner, the director of sexually transmitted disease prevention at the San Francisco Department of Health.

Amyl nitrates relax the body’s smooth muscle tissue while enlarging blood vessels, Klausner said.

"The vessels get larger and that lowers your blood pressure and that lowers the amount of blood that goes through your heart and into your brain," he said.

"That’s what the amyl nitrate does, and that’s a similar mechanism to what the Viagra does. It improves blood flow to the penis. So these two things, working in a similar way, cause an overdose of this effect and people have extremely low blood pressure," he said.

The drop in blood pressure sometimes provides enough of a scare to prompt users to shy away from the combination.

"The poppers had worn off a little bit and the Viagra is still kicking, but you’re not getting that high from the poppers," said a 33-year-old gay man who used poppers after taking a half-pill of Viagra during sex. "It kind of starts all along your scalp line, that’s kind of the first feeling, and then it goes down your body. For me, it made my chest warm and tight, like a lot of blood was stuck there."

He has taken Viagra when other recreational drugs have made it difficult to maintain an erection. But he doesn’t plan on mixing Viagra with poppers again.

"I knew that there was a risk of stroke," he said. "I learned from my mistake and consider myself very lucky."

Effects of the mixture

Some HIV educators aren’t as worried about the combined effects of Viagra and poppers as they are about how the drugs might affect sexual behavior.

As Viagra is becoming a more popular "club" drug, it is often being used with illegal drugs, including Ecstasy, methamphetamine or GHB, all designer drugs known to decrease sexual inhibitions.

"We know unprotected sex goes on when you mix poppers or other drugs together," James Loyce, deputy director of health for AIDS Programs at the San Francisco Health Department, told the San Francisco Chronicle. "It’s a lethal cocktail."

A recent survey of more than 800 men visiting an STD clinic attached numbers to the arguments of some health workers that Viagra and other drugs used as party favors by gay men may feed HIV infections.

Some 32 percent of the gay respondents said they had used Viagra in the past year, compared to 7 percent of those who are heterosexual, according to the San Francisco health department, which conducted the survey.

Many of the gay men said they combined it with Ecstasy and other recreational drugs.

The gay men who reported using Viagra also reported more sexual partners than gay men who did not use it and they were more likely to have an STD, according to the survey.

Some 30 percent of gay Viagra users who were HIV-negative said they had unprotected anal sex with HIV-positive partners or men of unknown HIV status. That compared to 15 percent of gay HIV-negative men who had not used Viagra.

"The combination of decreasing the inhibitions of people and the self control, people would be more likely to do risky behaviors, and with Viagra, they’ll be more able to perform a sexual act and be at a higher risk to transmit the HIV disease," said Dr. Phillippe Chiliade, a physician and HIV expert with the Washington, D.C.-based Whitman Walker Clinic.

"[Viagra] is running rampant in the gay male community," said GMHC's Algaze, adding, "and poppers do impair people's judgment -- and just like other recreational drugs, like alcohol, if their judgment is impaired, very often people will do sexually risky things -- and that causes HIV/AIDS sometimes."

Tony Braswell, executive director of AID Atlanta, an AIDS service organization, said that many men use Viagra for legitimate medical reasons or because certain HIV therapy medications have made it difficult for them to maintain an erection.

"Both are part of a complicated set of issues that we have to deal with as far as sexually transmitted diseases," Braswell said.

But he said the popularity of Viagra has made it easier for people to get their hands on the drug. The San Francisco survey showed that more than half of the respondents had gotten Viagra from a friend and not a doctor.

Even more dangerous, Chiliade said, is how Viagra can react to certain HIV cocktail therapies. He said that Retinovir can raise the level of Viagra in a person’s blood to dangerous levels.

Klausner said that highly active antiretroviral therapies, known as HAART, can block the metabolism of Viagra.

"If someone was to take a normal dosage of Viagra while being on those medications without being under a doctor’s medical care, they would overdose. And an overdose of Viagra will kill you," Klausner said. "Instead of taking 50 milligrams, it might be as if they took 500 milligrams."

The recreational use of Viagra prompted the Whitman-Walker Clinic to rethink its position on the drug, said Michael Cover, associate executive director of public affairs for the clinic.

"We’re taking a look at our own level of prescriptions of Viagra and looking at a policy of providing important information about the use of Viagra along with other drugs and the dangers associated with those," he said.

Klausner said he hopes the results of the recent survey will prompt Pfizer, Viagra’s manufacturer, to create an educational campaign for gay men about the drug.

Calls to the public affairs department at Pfizer were not returned by press time.

But a Pfizer spokesperson, Geoff Cook, told the New York Times last month that the company has long warned against the use of Viagra for nonapproved purposes.

"Our position to not use Viagra for recreational purposes is well-known, but any pharmaceutical product can be abused," Cook told the Times.

Pfizer also advises caution when Viagra is used with protease inhibitors, he said.

The lure of poppers

Some of the same questions that surround recreational use of Viagra -- does use of the drug recreationally lead to more risky sex, or are gay men who engage in unsafe sex more likely to use the drug? -- can be asked of poppers.

Some suggest alcohol would be more impairing to judgment than poppers, or that most men use poppers well into the sexual experience, usually close to orgasm.

Braswell, meanwhile, said a judgment call concerning condom use will most likely not be made during the high from amyl nitrates.

"People who don’t use condoms are not using condoms because of a judgment call that’s really based on a much more intense substance, like alcohol or an illegal drug," Braswell said. "You don’t make a decision in 90 seconds when the poppers wear off. It’s a chemical that’s bad for you, but I can’t sit here and tell you it’s the root cause of AIDS."

But in the early days of AIDS in the 1980s, poppers was considered a contributing cause to HIV infection.

When some gay men were being diagnosed with a very rare form of skin cancer, Kaposi’s Sarcoma, and its large skin lesions appeared, some health professionals argued that poppers caused KS -- because poppers increase the size of blood vessels at the skin level -- and in turn, HIV.

The speculation led to public controversy surrounding amyl nitrates, which in turn, led to the inhalant’s loss in popularity. Today, as the nitrates regain their popularity, health professionals find it difficult to say definitively whether poppers are dangerous.

"The literature on poppers is all over the map," Braswell said. "It’s a foreign chemical, so it’s not good to introduce into your body. But our concern as educators is that people would use it to try to stretch their body beyond limits that were safe."

Steve Morin, director of the University of California, San Francisco’s AIDS Policy Research Center, said the best way to combat abuse of drugs, including poppers and Viagra, that may lead to risky behavior is to talk about the issue.

He conducted a recent study that showed gay men are rarely talking about HIV and sex with their friends.

"People feel less social support for staying negative," Morin said.

Morin said his study showed a shift in community norms from safe sex being the norm to unsafe sex being an accepted option.

"Without a frank discussion in the community with your friends about HIV and what the consequences are, it’s very easy to have that community norm shift over time," he said.

Klausner said that communication should continue between patients and physicians, especially about the misuse of Viagra and poppers.

"They should be informing their physician about any kind of drug, over-the-counter, prescription drugs, illegal drugs, that they’re using," Klausner said. "A good doctor will not be judgmental. A good doctor will be thankful for the openness of the relationship and should be educating patients on how to use drugs safely."

The ABCs of poppers

by ERIC ERICKSON

There’s a wealth of information about poppers, but it’s difficult to find a consensus about whether the drug is dangerous.

In "The Stonewall Experiment: A Gay Psychohistory," author Ian Young outlines the interesting and often controversial history of video head cleaner.

In the book, published in 1999, Young courageously proclaims "poppers are back!"

Originally, amyl nitrate was used as a vascular dilator by people with angina.

"They just took a whiff of it on odd occasions when the old ticker felt funny," Young wrote.

The liquid nitrate came in small ampoules that were "popped" to release fumes, and the name "poppers" was conceived.

When nitroglycerin tablets were introduced for angina pain and it appeared poppers would disappear forever, they were introduced to military troops in Vietnam as an antidote to gun fumes.

When soldiers came back from war, they kept up the demand for poppers and a sexual fad was born as people realized poppers pepped up the sexual experience. It was especially helpful for gay men who needed help in relaxing to be a bottom.

Young stated that by 1978, the popper industry profited more than $50 million a year, largely, he said, by promoting them in the gay media.

With names such as "Rush," "Jac," and "Locker Room," amyl nitrate enjoyed extreme popularity until the ‘80s, when health officials linked the little brown bottle to AIDS.

Poppers returned in the ‘90s after their link to AIDS was largely dismissed. They are often disguised as video head cleaner, but can also be found as room deodorizer or liquid incense.

Typical physical effects include headache, flushing of the face, decreased in blood pressure, increase pulse, dizziness, relaxation of involuntary muscles especially the blood vessel walls and the anal sphincter.

There are no known withdrawal symptoms, although some people who use poppers said you can become addicted and rely on poppers to have sex.

Overdose symptoms include nausea, vomiting, decreased blood pressure and respiration, fainting, coldness of the skin. Circulatory collapse and death is also possible, especially when combined with certain other drugs.