Jun 24, 2002 7 min read

SAN FRANCISCO (AP) – Dr. Jeffrey Klausner realized he had to do something when he walked through one of the city’s sex clubs and heard pill wrappers crunching beneath his feet. “I picked one up, and it was a Viagra sample,” said Klausner, who heads the city health department’s sexually transmitted disease unit. “I thought, ‘What’s happening if people are using Viagra in sex clubs?”‘

His research soon showed that nearly a third of gay men surveyed at sexually transmitted disease clinics said they were using the anti-impotence drug Viagra, often in combination with illegal drugs that tend to encourage risky behavior.

Health experts say Viagra alone seems to pose no real danger to men who use it recreationally, even though they don’t need it to get erections.

But Klausner found that people who use it to offset the impotence effect of “party drugs” such as Ecstasy and crystal methamphetamine also acknowledged having unprotected sex with more partners, which can breed disease. And Viagra can be deadly if used with amyl nitrite, commonly called “poppers,” which some gay men take to facilitate sex.

Klausner’s study, published June 10 in the London-based journal AIDS, focused on a particularly high-risk group of men in San Francisco. But public health experts say other cities have similar subcultures where both gay and straight men combine Viagra with other drugs.

“It’s not just something going on at an STD clinic in San Francisco. This is actually pretty common,” said Patricia Case, who directs the Program on Urban Health at Harvard University and is studying “club drug” users in Boston and New York City for the National Institute on Drug Abuse.

At the Centers for Disease Control and Prevention, AIDS experts were already concerned about rising rates of STDs among gays and other young people who have become complacent about condom use because effective AIDS drugs allow infected people to appear healthy and live longer.

Now, Viagra needs to be studied more closely as another possible factor in sexually reckless behavior, said Dr. Ronald Valdiserri, the CDC’s deputy chief of sexually transmitted diseases.

“I see the Viagra story as sort of a subplot in all of this,” he said. “We take all of this very seriously.”

Sipping a drink with friends at a popular gay bar at the edge of San Francisco’s Castro District, Lim, a 22-year-old gay man, said Viagra is simply another part of the drug scene at the city’s five regulated sex clubs, and at nightclubs and raves.

Lim, who gave only his last name, says he began mixing Viagra with crystal meth or Ecstasy about two years ago. It takes about 30 minutes to kick in, he says, and can keep sex going strong for hours.

Lim says he’s never had to buy party pills, because if you’re “young and cute, it’s just there.”

Viagra is supposed to be available only by prescription, after a doctor’s consultation, at a cost of $8 to $10 a pill. However, Internet companies sell the drug to anyone who completes an online survey. Viagra then gets traded among friends or resold for $20 to $30 a pill.

Pfizer Inc., which introduced Viagra in 1998 and now makes about $1.2 billion a year on the drug, says it’s not responsible for drugs obtained without a prescription, or Viagra knockoffs made by someone else. “We were opposed to the recreational use of Viagra from day one,” said company spokesman Geoff Cook.

Pfizer has marketed Viagra mostly to men 40 and older who suffer from erectile dysfunction, but the little blue diamonds quickly became known for boosting the sexual stamina of younger, healthy men.

“Those of us really close to the street see what’s going on,” said Alan Brown, who runs the Electric Dreams Foundation, which promotes health at gay nightclubs nationwide. In the complicated mix of legal and illegal drugs partyers use, Viagra is considered a natural companion to drugs that remove inhibitions, Brown said.

The drug also is showing up among heterosexuals.

“I thought, ‘Hey, what a good idea,”‘ said a 33-year-old heterosexual man from San Francisco, recalling the time he first combined Viagra with Ecstasy.

“If I had not been on Ecstasy at the time I would have never thought of it,” he said, speaking on condition of anonymity.

He now uses Viagra regularly, and has combined it with Ecstasy twice in the past two years, although he considers it an “unsafe decision.”

The most worrisome combination, experts say, is Viagra with amyl nitrite. Called “poppers” because the liquid drug was first available in a capsule that was cracked or popped open to release vapors, amyl nitrite can cause a deadly drop in blood pressure.

Dr. Eric Christoff, a Chicago physician who has served as a medical volunteer at gay dance parties, says he warns his patients not to take Viagra with amyl nitrite, and he documents the warning in their medical records.

“I will say, ‘You cannot combine this with poppers. Don’t do it. Don’t even be in the same room with it.”‘

Still, Christoff says he prescribes Viagra “to lots of men in all age ranges. …If the person is using Ecstasy and can’t get an erection, then takes this to obtain one, is that a problem? I’m not sure that it is.”

So far, there has been little research on what happens when Viagra is taken with illegal drugs. “There have been fatalities – they just haven’t been published,” said Case, who is conducting the study of club drug users.

Dr. Edward Boyer, a Boston area toxicologist, believes it was Viagra and poppers that killed an otherwise healthy 48-year-old man he saw in an emergency room 11/2 years ago. The man had suffered a heart attack while at a place where gay men meet for sex.

Klausner is concerned about such fatalities, but he says a wider problem is the possible link between Viagra use and an alarming increase in STDs. His survey found that uninfected Viagra users were twice as likely to have unprotected sex with someone who is or might be infected with the AIDS virus, compared to those not taking Viagra.

In San Francisco, syphilis cases jumped to 183 in the first four months of this year, up from just 41 by April 1998. Rectal gonorrhea is up nearly 50 percent, and the city expects 750 to 900 new HIV infections this year, up from about 500 five years ago.

Klausner didn’t conclude that Viagra leads to these diseases, but said his study did show a significant correlation.

“It enables them to have more sexual partners and sex for longer periods of time,” he said. “Both of those are major factors for getting STDs.”

His survey of men at STD clinics showed Viagra users reporting more sexual partners than non-Viagra users.

The government has cracked down recently on abuse of Viagra and other prescription drugs. Internet pharmacies in California, Texas, Florida, Louisiana, Alabama and other states have been targeted, including a Los Angeles operation that allegedly filled more than 3,500 prescriptions for Viagra and other drugs without a “good-faith medical examination.”

Klausner and other public health officials also want stronger warning labels, including urging Viagra users to wear condoms.

Pfizer says Viagra labels and advertisements clearly indicate that the drug doesn’t protect against STDs. Cook, the Pfizer spokesman, said the drug maker also supports the crackdown on Internet sales and knockoff pills.

The Food and Drug Administration is reviewing Klausner’s complaints about Pfizer’s labels, said FDA spokeswoman Susan Cruzan.

But Viagra, which enables erections for up to 12 hours after taking it, may be just the beginning. Eli Lilly and Co. is developing another anti-impotence drug, Cialis, which promises to last 24 to 36 hours.