Transcript Anti-HIV Medications + Street Drugs

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 antiHIV 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 lifethreatening 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 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.
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.