Trending Now: Recreational Use of Viagra
Note from MTC: This article is the result of a question that was submitted to the Ask the Expert section of this website. Our guest experts’ response was so informative that we decided to feature this as an article.
“We are experiencing an increased number of young, healthy males reporting their recreational use of Viagra. Is this a problem? Are there any long-term effects that patients should be educated about? What should I be discussing with these patients?”
In recent years the use of phosphodiesterase 5 inhibitors (PDE5i), namely Viagra (Sildenafil) have become popular among young men without erectile dysfunction (ED).  Viagra is one of the most common medications mentioned on the television and in press. In fact, numerous jokes are told with Viagra as the butt of the humor making it a household name to most.  According to the manufacturer’s website, Viagra induces penile erections in 82% of men with erectile dysfunction yet only 24% in placebo patients. Despite these claims it is common knowledge “on the street” that Viagra increases penile size and may even extend the time to ejaculation in individuals without ED, making this a very popular drug for abuse. 
While we commonly refer to Viagra when discussing PDE5i, it is important to understand that all PDE5i have the same mechanism of action. Therefore, results from any of these studies using Viagra can be inferred to all PDE5i.
Studies report rates as high as 21.5 % of men aged 18-30 years ingesting Viagra recreationally, with 73.3% of that population admitting to using it more than once.  More surprising is evidence showing that Viagra use is increasing in prevalence in men and women, yet decreasing in age, with a mean age of users being 25 years old in a 2003 report.  Reasons for why this trend exists are likely due to the overall sexual health improvement reported by 72.5% of men using PDE5i. Men claim it “enhances their sexual performance” improving desire and “warm sensations” and prevents sexual failure. Other reasons young men have reported to taking Viagra recreationally were a willingness to have a harder and longer lasting erection, desiring a higher coital frequency, and to delay ejaculation. In another study 27.5% of men who took Viagra stated their main reason was out of pure curiosity. 
While we clearly have young men abusing this drug for recreational purposes, we may have a subset of young men taking it to self-medicate ED. There is limited data currently on ED in adolescents, however, one study looking at a sample of men aged 18-29 years had 13% of adolescents reporting ED, which they stated they had not discussed with their physician. Additionally, 25% of the study’s population reported having ED with condom use, resulting in a total of 1 in 8 young males reporting ED and 1 in 4 reporting ED with condom use. 
So is this a problem?
Several issues are concerning regarding this new trend. First, is the fact that the majority of these men are obtaining Viagra without medical prescriptions or supervision. This is dangerous. In a study by Bechara et al, they evaluated the recreational use of Viagra among 379 men. Of the 69 men who reported using Viagra recreationally, 75.4% reported obtaining it from a friend and 17.4% from a pharmacy without a prescription. Obtaining Viagra from friends, the internet, pharmacies, and sex shops were among the most commonly reported places.  This shows a clear lack of control and regulation for this drug, as well as a lack of education about the recommendations and indications for Viagra’s use. 
This leads to a second concern. The use of Viagra is strongly cautioned in patients who take certain medications or have specific medical conditions.Warnings have been around for years about the use of Viagra in conjunction with nitrates because of the resultant blood pressure lowering.
Additionally, other drugs interfere with the metabolism of Viagra in the body. Patients taking erythromycin, diflucan, amiodarone, diltiazem, losartan, nefidipine, all statin drugs, alprazolam, Zoloft, protease inhibitors, and or acetaminophen, should be very careful about combining these medications with Viagra. [2, 3] If patients are taking Viagra without medical supervision, they could be potentiating some very serious adverse effects. While young men often do not have chronic or debilitating heart conditions, men with a history of cardiovascular disease, exercise intolerability and other comorbidities should be warned against taking Viagra which may result in consequential side events. 
Perhaps the most alarming and concerning issue of all, regarding the use of Viagra recreationally in young men is the strong association of its use in combination with recreational drugs and alcohol.[1-6] In studies, PDE5i were used most commonly in night clubs as a recreational drug in combo with alcohol and other drugs. Oftentimes, men are taking Viagra to negate the negative sexual side effects that many recreational drugs, including alcohol induce.
Studies have reported that over half of PDE5i use is associated in combination with alcohol, illicit drugs and psychotropic medication ingestion.  There is also a strong association between men who use cannabis and men who obtain Viagra from sources other than a licensed physician. 
Viagra is metabolized in the body predominately by the cytochrome p450 system. This is a system found in the liver that is responsible for the metabolism of numerous substances in our bodies. Viagra’s vasodilatory effects can be potentiated by substances we call “p450 inhibitors.” Cannabis is a known inhibitor of this system and thus, results in Viagra having higher vasodilatory effects in those men taking both substances together.  Other medications, such as protease inhibitors, taken with Viagra will extend the half-life of Viagra, making it last longer. This combination is commonly used in the HIV community as well as in the public. 
What are the LT effects patients should be counseled about?
The result of the recreational combination of drugs and medications in young men can often have lifelong consequences. When individuals are on these recreational drugs they are in an altered state with impaired decision-making capabilities. This often leads to poor choices with regard to risky sexual behaviors, and unsafe sexual practices resulting in unwanted pregnancies and an increased risk for sexually transmitted diseases (STDs), including HIV. [4,5] In fact studies have strongly linked the two together, correlating Viagra use with risky sexual behaviors including multiple partners, higher rates of sexually transmitted infections (STIs) and a greater increase in unprotected sex with HIV positive men, in men who have sex with men (MSM). [4, 5]
Alcohol and drugs, such as ecstasy and methamphetamines, elevate the motivation for sex and reduce inhibitions, but can also induce erectile dysfunction as the drugs vasoconstrict peripheral blood vessels impairing sexual performance. [4, 5] This may explain the high prevalence of these drugs in combination as Viagra serves to counter the negative sexual side effects.
An extensive review comparing multiple variables in MSM who used Viagra, compared with similar patients who did not use Viagra gave frightening reports. Among patients who used Viagra, there was a significant 2- to 5.7-fold increased practice of unsafe sex compared with those patients who did not use Viagra. Additionally, the rate of sexually transmitted diseases was nearly 2-fold greater in the individuals who used Viagra. 
More recently, Fisher et al performed an updated review on Viagra use and the combined use of Viagra with methamphetamines. They reported that heterosexual men who took Viagra were more likely to have insertive anal intercourse with women which was associated with heterosexual transmission of HIV from men to women.  There are multiple studies showing a relationship between the use of Viagra and being HIV positive.
Earlier criticisms of the purported link between Viagra use and STDs including HIV infection were mostly based on the fact that other drugs were also taken with Viagra that were responsible for the association of Viagra use and STD/HIV incidence. However, there are now more sophisticated statistical analyses that show, after controlling for sexual risk behaviors, use of Viagra itself is significantly predictive of HIV infection as well as other STDs.  The increased duration of erection, increased blood flow, and subsequent increased mucosal susceptibility may increase the risk of acquiring these infections if having sex with an infected partner. 
In a multivariate analysis of a study conducted in Chicago and Los Angeles, Viagra and Nitrates were directly associated with recent HIV seroconversion. 
This study also showed that the combination of meth, Viagra, and poppers increased the risk for HIV seroconversion from 2.99% for those using only one drug to 8.45% in those using all three drugs. 
What should I be discussing with these patients?
The recreational use of Viagra or other PDE5i, have huge implications on a public health level and may lead to severe consequences for these men. Educational programs, particularly among physicians, men who have sex with men, and methamphetamine users, should be implemented to increase awareness regarding the use of PDE5i and their association with STDs. Focused action is needed to respond to this public health problem.
A collaborative effort among health care professionals and policy makers is necessary to avoid selling Viagra without a prescription. Healthcare providers need to give adequate and appropriate information to patients regarding the use and misuse of these PDE5i.
Education is paramount to promote safe sex, correct condom use and the need for medical supervision of PDE5i use. Given the association between ED and negative health outcomes, medical providers should ask adolescents about ED and counsel them on the potential health risks of PDE5i as well as on substance abuse. Providers should specifically inquire about ED with condom use in adolescents as the importance of using condoms with all sex encounters cannot be emphasized enough.
1. Bechara A, Casabé A, De Bonis W, Helien A, Bertolino MV. Recreational Use of Phosphodiesterase Type 5 Inhibitors by Healthy Young Men. J Sex Med. 2010 Aug 16.
2. Alpert JS. Viagra: the risks of recreational use. Am J Med. 2005 Jun; 118(6):569-70.
3. Corona G, Razzoli E, Forti G, Maggi M. The use of phosphodiesterase 5 inhibitors with concomitant medications. J Endocrinol Invest. 2008 Sep; 31(9):799-808.
6. Fisher DG, Reynolds GL, Napper LE. Use of Crystal methamphetamine, Viagra, and sexual behavior. Curr Opin Infect Dis. 2010 Feb; 23(1):53-6.
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