Interaction of Street Drugs with HIV Medications

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• 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
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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.

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Anti-HIV Medications Street Drugs

• There hasn't been much research on how street
  drugs and HIV medications interactbecause 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.

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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.

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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 Xso
  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
199835217512.
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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 soalthough because effects
  in the test tube have sometimes been opposite to
  those seen in the body, this is hard to predict.

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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.

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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 Oct36(10)1598-613.
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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.

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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.

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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.

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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.

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Barbiturates

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

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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.

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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.

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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.

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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.

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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
199915922214.
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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!

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LSD (acid, blotters)

• No known interactions.

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Mushrooms(shrooms, boomers, psilocybin)

• No known interactions.

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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.

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Ketamine (Special K)

• When combined with Norvir, special K can lead to
  "chemical hepatitis," an unpleasant inflammation
  of the liver resulting 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.

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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.

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Ritalin

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

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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.

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Strategies

• Stay healthyeat 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.

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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 Oct36(10) p.1598-613.
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Interactions Between Antiretrovirals and Rave
Drugs
Source Antoniou T, Tseng AL. Interactions
between recreational drugs and antiretroviral
agents. Ann Pharmacother 2002 Oct36(10)1598-613.