Interaction of Street Drugs with HIV Medications

Interaction of Street Drugs with HIV Medications Prepared by Mark Kinzly & Nabarun Dasgupta, Doug Bruce, MA MD. Yale School of Epidemiology and Public Health, Yale AIDS Program

Anti-HIV Medications + Street Drugs • For most drugs to be effective and not kill you, they need to be metabolized [broken down] by the liver or kidneys. These organs have limited resources and a set number of chemicals which accomplish this task. Because of this, certain drugs, whether they're HIV medications or recreational drugs, can affect how other drugs act. • This is called a drug interaction— and some of them can be deadly.

Anti-HIV Medications + Street Drugs There hasn't been much research on how street drugs and HIV medications interact—because there is little financial incentive for the pharmaceutical companies to do the work, and because the government believes "just say no," is the only way to deal with drugs. Certainly, your best bet is not to take street drugs at all if you are taking HIV medications. But some interactions are deadlier than others.

Two Types of Interactions • You need the HIV medications! Some street drugs will reduce the effectiveness of antivirals, leading to resistant strains. • Some HIV meds magnify the effects of street drugs, causing you to overdose. Both can kill you… …or you lose the high.

Ecstasy (X, MDMA) • There has already been one death in England which resulted from a regular dose of ecstasy (MDMA, X) taken with Norvir (ritonavir). Norvir acts to slow down the liver enzyme that breaks down X—so it makes the dose 5 to 10 times stronger. • In addition, between 3-10% of the white population (the figure for other populations is not known) have a deficiency in this enzyme, which may be why some people overdose on what may be a safe dose for others. • Since the amount of X varies in each pill, it is difficult to know how much will put you in danger. Source: Henry JA, Hill IR. Fatal interaction between ritonavir and MDMA. Lancet 1998;352:1751–2.

Ecstasy (X, MDMA) • If you are taking any protease inhibitor [ritonavir (Norvir), nelfinavir (Viracept), indivar (Crixivan) saquinavir (Fortovase)] or non-nucleoside reverse transcriptase inhibitor [neveripaine (Viramune)] delavirdine (Rescriptor) or efavirenz (Sustiva)], X can be extremely dangerous. • Of these, ritonavir and delavirdine seem to be the most dangerous, while neveripaine and efavirenz may be less so—although because effects in the test tube have sometimes been opposite to those seen in the body, this is hard to predict.

Ecstasy (X, MDMA) • If you do take X with a protease inhibitor, wait as long as possible after taking the protease inhibitor to take the X, and be sure to have someone with you who knows what you've done in case you have difficulties. These overdoses are often not reversible, so it's really better not to mix these drugs! • Recent research has found that X damages serotonin neurons, so avoid it if you have a family or personal history of depression or anxiety disorders. • Taking X while on HAART may lead you to roll for much longer. Some people have reported rolling for 30 hours from two pills while taking ritonavir and saquinavir.

Ecstasy (X, MDMA) Recommendations from HIV Program/Inner City Health, St. Michael's Hospital, Toronto, Canada. • Use 25% of the usual amount of MDMA • Take breaks from dancing • Make sure rave or party has medical team on site • Maintain adequate hydration by avoiding alcohol and replenishing fluids regularly Source: Antoniou T, Tseng AL. Interactions between recreational drugs and antiretroviral agents. Ann Pharmacother 2002 Oct;36(10):1598-613.

Alcohol Videx (ddI) can increase the risk of pancreatitis (intense stomach pain that feels like it's going all the way through to your back. So, if you're using alcohol regularly, don't use Videx. There are other nucleosides to choose from.

Alcohol Occasional and light use of alcohol is not known to interact with other HIV medications; however, chronic, heavy use can be destructive to the liver. This can be dangerous because the way drugs are broken down can be hurt. More drugs will stay in your system for the most part, which is likely to cause overdoses and worse side effects. Alcohol can cause dehydration; so be sure to drink lots of water to help your body deal with any alcohol you drink.

Marijuana • Protease inhibitors may increase THC levels (the active ingredient in marijuana)—so smaller doses may make you more stoned. This is also true of the synthetic version (Marinol) used in the treatment of weight loss. Since THC overdose is impossible, this interaction is not dangerous.

Sedatives • The sedatives Halcion (triazolam), Valium (diazepam), Ambiem (zolpidem) and Versed (midazolam) can also be deadly if mixed with protease inhibitors. Norvir has the largest negative effect. At high doses these drugs can stop your breathing. Ativan (lorazepam), Serax (oxazepam) and Restoril (temazepam) are safer with Norvir, and may actually be weakened by it.

Barbiturates • Crixivan may increase blood levels of phenobarbital (Luminal), making overdose more likely. Other protease inhibitor interactions are also possible.

Cocaine (coke, blow) • There are no known interactions between cocaine and HIV medications, but in the test tube, cocaine doubles the speed at which the virus reproduces, meaning it may speed up how sick you get.

Heroin (smack, brown, junk, China White) • Norvir seems to reduce heroin levels by 50% making overdose less likely. However, this drug and the other protease inhibitors have sometimes been known to have opposite effects (they cut methadone levels in real life, while test tube experiments predicted they would increase them), so caution is in order. • Some synthetics sold as heroin (fentanyl, alpha-methyl-fentanyl) are potent in tiny doses and could be deadly if mixed with another drug.

Methadone (done) • Interactions between methadone and NNRTIs and PIs are highly likely. • Sustiva and Viramune may cause withdrawal if taken while using methadone. People on methadone maintenance may need higher doses of the opiate. Norvir, Viracept, and possibly Kaletra may also cause similar problems.

Methadone (done) • Methadone may cause nucleosides to build up in the body and lead to toxicity from AZT. Patients should be monitored for toxic reactions to AZT including nausea, vomiting, headaches and low blood platelet levels. • Methadone may decrease the anti-HIV action of Videx/ddI and Zerit while taking methadone. This could lead to resistance in the virus and the creation of more powerful strains of HIV. Taking the pill form (and not the syrup) is thought to allow the drugs to pass through the stomach without methadone weakening them.

GHB,Liquid X • GHB is potentially dangerous with Norvir and other protease inhibitors. • One man had serious life-threatening conditions after taking a small amount of GHB to come down from an X trip. He was on ritonavir and saquinavir at the time and had taken similar does of the rave drugs without problems in the past. Source: Harrington RD, Woodward JA, Hooton TM, Horn JR. Life-threatening interactions between HIV-1 protease inhibitors and the illicit drugs MDMA and gamma-hydroxybutyrate. Arch Intern Med 1999;159:2221–4.

Amyl nitrite (amyl nitrate/poppers) • Glutathione is used by the liver to process amyl nitrite, and high glutathione is linked with survival. If using amyl nitrite cuts glutathione, it could lead to disease progression. • NO VIAGRA!

LSD (acid, blotters) • No known interactions.

Mushrooms(shrooms, boomers, psilocybin) • No known interactions.

PCP (angel dust, morning glory) • PIs, Rescriptor, and possibly Sustiva work in the same liver pathway that PCP is broken down in. Taking PCP while using these drugs may result in high PCP concentrations and cause toxic shock and/or death.

Ketamine (Special K) • When combined with Norvir, special K can lead to "chemical hepatitis," an unpleasant inflammation of the liverresulting in jaundice. A New York HIV doctor has seen two cases of it. Both went away in several weeks. But anything which damages the liver can be a serious problem for people living with HIV. • Norvir, Viracept and Sustiva are suspected to cause special K to build up in the body and lead to toxic shock.

Amphetamines (dexedrine, amphetamine, methamphetamine, crystal meth) • Amphetamines work the same way that X does in your body. As with X, Norvir (ritonavir) should be avoided. • Norvir is predicted to increase amphetamine levels in the blood by a factor of 2-3. • The other protease inhibitors should have less of an impact, but strange opposite results are always possible.

Ritalin • Norvir and other similar drugs can either strengthen Ritalin's effects or make it weaker. Beware!

Anti-HIV Medications + Street Drugs • Interactions not listed could be deadly. Street drugs are often not what they are sold as, they are frequently cut with substances that may interact with drugs themselves and their potency can vary wildly, even in the same batch. With the lack of research in this area, it's better to avoid potential interactions if at all possible.

Strategies • Stay healthy…eat well, get rest when taking HIV meds. • Try the jelly bean strategy first when starting a new HIV medication. • Ask a pharmacist about interactions with morphine (for heroin), ephedrine (speed). • Read up on interactions. Look online and the PDR.

For More Information… A recent article in the Annals of Pharmacotheraphy reviews the science and medical cases of HIV med and street drug interactions. There are also references in the article to studies, data, etc. that may be of interest. Antoniou T, Tseng AL. Interactions between recreational drugs and antiretroviral agents. Ann Pharmacother 2002 Oct;36(10): p.1598-613.

Interactions Between Antiretrovirals and Rave Drugs Source: Antoniou T, Tseng AL. Interactions between recreational drugs and antiretroviral agents. Ann Pharmacother 2002 Oct;36(10):1598-613.

Interaction of Street Drugs with HIV Medications