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Table of Contents

1. Introduction
2. Medical Use and Approval
3. Recreational Use and Associated Risks
   • Recreational Abuse in South Africa
   • Unconfirmed Presence in Whoonga
4. Chemistry of Efavirenz
   • Unique Chemical Structure
   • Physical and Chemical Properties
5. Pharmacology of Efavirenz
   • Mechanism of Action as an NNRTI
   • Additional Pharmacological Effects
   • Bioavailability and Drug Testing
6. Dosage and Bioavailability of Efavirenz
   • Dosage
   • Bioavailability
7. Subjective Effects of Efavirenz
   • Disclaimer
   • Physical Effects
   • Visual Effects
   • Hallucinatory States
   • Cognitive Effects
   • Auditory Effects
8. Toxicity and Harm Potential
   • Tolerance and Addiction Potential
   • Dangerous Interactions
     • Hepatoxicity Risk
     • Serotonin Syndrome Risk
9. Legal Status

Efavirenz: An Overview

Introduction

Efavirenz, marketed under the brand name Sustiva, is an antiretroviral medication widely used in the treatment and prevention of HIV/AIDS. This medication is particularly notable for its unique ability to produce psychedelic and hallucinogenic effects, a characteristic not commonly associated with other antiretroviral drugs. Its pharmacological profile and chemical structure are exceptionally novel and distinct from those of traditional psychedelic substances.

Medical Use and Approval

Efavirenz was approved for medical use in the United States in 1998. Its efficacy and safety have earned it a place on the World Health Organization's List of Essential Medicines, which includes the most effective and necessary medications for a health system. This designation underscores the critical role efavirenz plays in the management of HIV/AIDS globally.

Recreational Use and Associated Risks

Recreational Abuse in South Africa

Despite its medical importance, efavirenz has also been misused for its hallucinogenic and dissociative effects. In South Africa, reports have surfaced of individuals crushing and smoking efavirenz tablets in a mixture commonly referred to as "whoonga," "nyaope," or "wonga." This mixture is often believed to contain a form of black tar heroin.

Unconfirmed Presence in Whoonga

However, analyses of whoonga samples have yet to confirm the presence of efavirenz in these mixtures definitively. This lack of confirmation suggests a need for further research to determine the exact components of whoonga and the potential risks associated with its use.

Efavirenz remains a cornerstone in the treatment and prevention of HIV/AIDS, recognized for its safety and efficacy. Nonetheless, its potential for recreational abuse highlights the necessity for continued monitoring and education to prevent misuse and to address the health risks associated with non-medical consumption.

Chemistry of Efavirenz

Unique Chemical Structure

Unlike most psychedelics, efavirenz does not belong to the tryptamine, phenethylamine, or lysergamide classes. Instead, efavirenz is classified as a benzoxazine. Its chemical structure includes several distinct moieties that contribute to its unique pharmacological profile. Notably, the benzoxazine ring at the two-position is attached to a ketone group. Additionally, efavirenz features a trifluoromethyl group and a cyclopropane ring, distinguishing it further from other substances in its pharmacological class.

Physical and Chemical Properties

Efavirenz is characterized by its physical form as a white to slightly pink crystalline powder. It has a molecular mass of 315.68 g/mol and is practically insoluble in water, with solubility less than 10 µg/mL. Chemically, efavirenz is described as (S)-6-chloro-(cyclopropylethynyl)-1,4-dihydro-4-(trifluoromethyl)-2H-3,1-benzoxazin-2-one. Its empirical formula is C14H9ClF3NO2, reflecting its complex structure.

Pharmacology of Efavirenz

Mechanism of Action as an NNRTI

Pharmacologically, efavirenz is primarily classified as a non-nucleotide reverse transcriptase inhibitor (NNRTI). Reverse transcriptase is an enzyme that allows viruses such as hepatitis and human immunodeficiency virus (HIV) to transcribe viral RNA into DNA, facilitating their replication. Efavirenz inhibits this process, effectively blocking viral replication. Unlike nucleotide-based reverse transcriptase inhibitors, efavirenz’s structure is not derived from nucleotides, hence its classification as a non-nucleotide inhibitor.

Additional Pharmacological Effects

In addition to its primary role as an NNRTI, efavirenz exhibits several other pharmacological activities:

• 5-HT2A Partial Agonist: Similar to LSD, efavirenz acts as a partial agonist at the 5-HT2A receptor, contributing to its hallucinogenic effects.
• Serotonin and Dopamine Reuptake Inhibition: Efavirenz inhibits the reuptake of serotonin and dopamine, increasing the levels of these neurotransmitters in the brain.
• Vesicular Monoamine Transporter 2 Inhibition: By inhibiting this transporter, efavirenz affects the storage and release of monoamine neurotransmitters.
• GABAA Positive Allosteric Modulator: Efavirenz enhances the effect of GABA at the GABAA receptor, similar to the action of benzodiazepines and barbiturates.

Bioavailability and Drug Testing

Efavirenz has a bioavailability of approximately 40-45% when taken on an empty stomach, indicating a significant proportion of the drug reaches systemic circulation following oral administration. However, it is important to note that efavirenz can cause false-positive results for cannabis in some urine tests, which could have implications for patients undergoing drug screening.

Efavirenz stands out not only for its critical role in the treatment of HIV/AIDS but also for its unique chemical structure and diverse pharmacological activities. Understanding these properties is essential for appreciating both its therapeutic benefits and its potential for misuse.

Dosage and Bioavailability of Efavirenz

Dosage

Efavirenz is typically prescribed in doses ranging from 600 mg to 1800 mg, depending on the patient's specific medical condition, response to treatment, and other factors determined by a healthcare provider. This range allows for flexibility in dosing to optimize therapeutic outcomes while managing potential side effects.

Bioavailability

The bioavailability of efavirenz is approximately 50%. This means that when efavirenz is taken orally, about half of the administered dose reaches the systemic circulation. Bioavailability can be influenced by various factors, including whether the medication is taken with or without food. It's important for patients to follow their healthcare provider's instructions regarding the timing and conditions for taking efavirenz to ensure maximum efficacy.

Subjective Effects of Efavirenz

Disclaimer

The effects listed below are derived from the Subjective Effect Index (SEI), which is based on anecdotal user reports and analyses by PsychonautWiki contributors. As such, these effects should be viewed with skepticism. The occurrence and intensity of these effects can vary widely among individuals. Higher doses are more likely to induce a full spectrum of effects, but also increase the likelihood of adverse effects, including addiction, severe injury, or death ☠.

Physical Effects

• Physical Euphoria: Generally mild.
• Difficulty Urinating
• Nausea
• Dizziness
• Headaches
• Spontaneous Physical Sensations
• Stimulation or Sedation
• Appetite Suppression

Visual Effects

Enhancements

• Color Enhancement
• Pattern Recognition Enhancement
• Visual Acuity Enhancement

Distortions

• Drifting: Includes melting, breathing, morphing, and flowing effects.
• Afterimages
• Color Replacement
• Color Shifting
• Recursion
• Scenery Slicing
• Symmetrical Texture Repetition
• Tracers: The most common visual effect of efavirenz.

Geometry

• Generally mild and may not occur for many users.

Hallucinatory States

• Transformations
• Internal Hallucination: Includes autonomous entities, settings, sceneries, landscapes, perspective hallucinations, and scenarios/plots.
• External Hallucination: Includes autonomous entities, settings, sceneries, landscapes, perspective hallucinations, and scenarios/plots.

Cognitive Effects

• Anxiety or Anxiety Suppression
• Psychosis: Possible at very high doses.
• Unity and Interconnectedness: Generally mild.
• Confusion
• Introspection
• Dream Potentiation: Non-recreational doses often induce strange dreams.
• Disinhibition

Auditory Effects

• Auditory Enhancement
• Auditory Distortion
• Auditory Hallucination

Toxicity and Harm Potential

Efavirenz has relatively low toxicity relative to dose. Like many HIV medications, it can cause liver toxicity at high doses or with chronic use. Harm reduction practices are strongly recommended when using this drug.

Tolerance and Addiction Potential

Efavirenz is not known to be habit-forming, and developing a tolerance to it is extremely rare. However, abusing efavirenz may cause HIV to become resistant to the drug and increase the viral load in patients with HIV.

Dangerous Interactions

Hepatoxicity Risk

As efavirenz may cause hepatoxicity at high doses or with chronic use, it should not be taken concurrently with other substances that may cause hepatoxicity. Efavirenz induces the CYP2B6 and CYP3A4 enzymes of the cytochrome P450 system, which can alter the metabolism of other drugs metabolized by these enzymes. Consuming garlic may decrease serum levels of efavirenz.

Serotonin Syndrome Risk

Efavirenz is a weak serotonin reuptake inhibitor, so combining it with other substances that affect serotonin levels can lead to serotonin syndrome, a potentially fatal condition that requires immediate medical attention. The following substances pose a risk:

• MAOIs: Such as banisteriopsis caapi, syrian rue, phenelzine, selegiline, and moclobemide.
• Serotonin Releasers: Such as MDMA, 4-FA, methamphetamine, methylone, and αMT.
• SSRIs: Such as citalopram and sertraline.
• SNRIs: Such as tramadol and venlafaxine.
• 5-HTP

Legal Status

Efavirenz is not known to be illegal in any jurisdictions and is considered a prescription-only medication.

• Germany: Efavirenz is a prescription-only medicine, according to Anlage 1 AMVV.
• Switzerland: Efavirenz is listed as a "Abgabekategorie A" pharmaceutical, requiring a prescription.

Frequently Asked Questions (FAQ)

What is Efavirenz used for?

Efavirenz is an antiretroviral medication used in the treatment and prevention of HIV/AIDS. It helps to control HIV infection and improves the immune system.

How does Efavirenz work?

Efavirenz works primarily as a non-nucleotide reverse transcriptase inhibitor (NNRTI), blocking the enzyme reverse transcriptase, which is crucial for the replication of HIV. It also has additional pharmacological effects, such as being a partial agonist at the 5-HT2A receptor and inhibiting serotonin and dopamine reuptake.

What are the common dosages of Efavirenz?

Efavirenz is commonly prescribed in doses ranging from 600 mg to 1800 mg, depending on individual patient needs and medical advice.

What are the side effects of Efavirenz?

Side effects can include physical euphoria, difficulty urinating, nausea, dizziness, headaches, spontaneous physical sensations, stimulation or sedation, and appetite suppression. Higher doses may also lead to visual and cognitive effects, as well as auditory enhancements.

Can Efavirenz be used recreationally?

While Efavirenz has been reported to be used recreationally for its hallucinogenic and dissociative effects, such use is not recommended due to the potential for adverse effects and health risks, including psychosis, liver toxicity, and the possibility of causing HIV to become resistant to the medication.

What are the risks associated with recreational use of Efavirenz?

Recreational use can lead to severe adverse effects, including psychosis, addiction, severe injury, or death. It can also cause liver toxicity, particularly at high doses or with chronic use.

Is Efavirenz habit-forming?

Efavirenz is not known to be habit-forming, and developing a tolerance to it is extremely rare. However, abusing the drug can cause HIV to become resistant to it, increasing the viral load in patients with HIV.

Are there any dangerous drug interactions with Efavirenz?

Efavirenz may interact dangerously with substances that cause hepatoxicity, other medications metabolized by CYP2B6 and CYP3A4 enzymes, and drugs that affect serotonin levels, potentially leading to serotonin syndrome.

What is the legal status of Efavirenz?

Efavirenz is a prescription-only medication and is not known to be illegal in any jurisdictions. It requires a prescription in countries like Germany and Switzerland.

Can Efavirenz cause false positives in drug tests?

Yes, Efavirenz is known to cause false-positive results for cannabis on some urine tests.