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Cocktails and Party Favors

Spring 2002

The "club drug" epidemic is spreading. According to a Drug Abuse Trend report published by the National Institute on Drug Abuse (a division of the National Institutes of Health), there appears to be an alarming increase in the use of ecstasy, GHB, and ketamine in almost all cities surveyed. Methamphetamine use appears to remain concentrated on the West Coast and has been associated with an increased number of emergency room visits in Seattle. Other drugs of abuse identified by this report include cocaine, heroin, marijuana, benzodiazepines (clonazepam [Klonopin], alprazolam [Xanax], diazepam [Valium]), sildenafil (Viagra), and various prescription narcotics. With the increasing popularity of such drugs, there is concern that their use can potentially lead to serious health problems. For example, what happens when "club drugs" are mixed with HIV medications?

There has been a lot of interest regarding how recreational drug use may affect HIV infection and antiretroviral therapy. The most obvious concerns are as follows:

  • There is concern that some recreational drugs may weaken the immune system, possibly speeding up the progression of HIV disease.

  • There is concern that recreational drug use could interfere with one's ability to adhere to antiretroviral therapy, possibly leading to viral resistance.

  • There is concern that combining HIV medications with recreational drugs might result in a drug interaction, which could either decrease the effectiveness of one's antiretroviral therapy, or cause a serious side effect.

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The intention of this article is to focus on the area of drug interactions between HIV medications and recreational drugs. It will help to first understand the definition of a drug interaction.

A drug interaction happens when a person takes two drugs and one or both of the drugs behave differently when taken together than they would if taken alone. In other words, one of the medications changes the effects of the other. In some situations, drug interactions are not a problem. In other situations, drug interactions can affect one's therapy or even cause serious harm. The most common type of drug interaction that is seen with HIV medications is related to how a drug is metabolized (broken down) by the body.

The liver is the major organ that is involved in the metabolism of most HIV medications (particularly protease inhibitors and non-nucleosides). The liver is also used to break down some recreational drugs. To confuse things, some drugs, especially protease inhibitors, can also slow down (inhibit) how the liver clears other medications from the body. When two medications in the body are waiting in line to be broken down by the liver, they often have to compete. Protease inhibitors, such as ritonavir, are stronger and often win the competition. In this situation, the second medication is not cleared as quickly, often resulting in increased levels in the bloodstream. If drugs such as recreational drugs are present in the bloodstream in larger than usual concentrations, they can be dangerous.

On the flip side, some medications can speed up (induce) how the liver clears other medications from the body. When this happens, the second medication is cleared faster from the body and there is not enough medication around to do its work. Inducers can cause some HIV medications to be removed from the bloodstream and this can lead to viral resistance.

Quite a bit is known about drug interactions with protease inhibitors and other HIV medications. Unfortunately, there is minimal information available regarding drug interactions with recreational drugs. Little research is being done on this topic because there is a lack of financial incentive for drug companies to fund research due to ethical concerns and the fear of being recognized as supporters of illicit drug use. Based on what we already know about how certain drugs are cleared from the body, we can guess that mixing certain combinations together could lead to danger.

The best way to avoid potentially serious interactions is to not mix recreational drugs with antiretroviral therapy. However, if you choose to mix them, you should at least be aware of the risks involved. The table below is a list of suspected drug interactions that may occur between HIV medications and recreational drugs.


Mixing Cocktails: Recipes for Concern
Recreational DrugInteractions and Possible EffectsIdeas to Reduce the Risk (No Guarantees!)
AlcoholAntiretrovirals (ARVs)
There is not a direct interaction between alcohol and ARVs. However, it is possible that chronic alcohol use can increase the risk of drug toxicities such as liver damage (with protease Inhibitors, nevirapine, d4T), pancreatitis (with ddI, ddC), and neuropathy (with ddI, d4T, ddC).
There is an established association between excessive alcohol use and poor adherence to ARVs. It would be ideal to achieve sobriety prior to starting HAART. If sobriety is not a possibility and there is a need to start HAART, avoid a ddI-containing regimen as it may increase the risk of pancreatitis.
GHB and alcohol are both central nervous system (CNS) depressants. When mixed together, alcohol can increase the potential for seizures, difficulty breathing, and GHB coma.Avoid mixing with GHB!
Sedatives such as diazepam (Valium), triazolam (Halcion), temazepam (Restoril), and many others, are, like alcohol, CNS depressants. When mixed together, they can lead to prolonged sleep and possibly decreased breathing.Avoid mixing with sedatives!
Amyl Nitrate (Poppers)Viagra
May result in extremely low blood pressure which can potentially be fatal.
Do not mix!
Cocaine (Coke, Blow)Antiretrovirals (ARVs)
There are no known interactions between cocaine and ARVs. There is one test-tube study to suggest that cocaine may cause HIV to reproduce 20 times faster than normal. However, a definite correlation between cocaine use and viral load has not been established.
Long-term cocaine use can lead to problems with attention and concentration, memory loss, and decreased speed in processing information. Cocaine usage promotes a disorganized behavior, which can lead to missing ARV doses and ultimately to drug resistance.
Crystal Methamphetamine (Crystal Meth, Crystal, Speed, Ice)Protease Inhibitors (PIs)
There is a theoretical concern that PIs, particularly ritonavir, can decrease the clearance of crystal. This interaction could result in a 2- to 3-fold buildup of crystal in the blood, possibly leading to an overdose.
Start with lower doses of crystal (1/3 to 1/2 of normal dose) to account for possible enhanced activity by protease inhibitors.

If injecting, use clean and safe technique.

As with cocaine and other binge drugs, there is a concern that the use of crystal can lead to a lapse in taking HIV medications.

Long Term Crystal Use
Long-term use of crystal can lead to weight loss, poor nutrition, lack of sleep, and fatigue which might lead to further immunosuppression.
Ecstasy (E, X, MDMA)Antiretrovirals (ARVs), particularly PIs (ritonavir) and delavirdine, may cause a 3- to 10-fold increase in ecstasy levels in the bloodstream, leading to an overdose.

To date, there has been at least one death caused by an ecstasy overdose that may be the result of an interaction between ecstasy and the PI ritonavir.

Mixing "X" with PIs is likely to increase levels of "X" as well as prolong the "high." If mixing the two, it is advisable to start with 1/4 to 1/2 tablet and wait for effect.

"X" can increase your body temperature and cause you to sweat, especially if you are dancing in a hot environment. Take frequent breaks to cool off.

It is important to drink plenty of fluids, especially if taking indinavir (Crixivan) or if combining ecstasy with alcohol. Alcohol will increase the risk of dehydration.

If you have high blood pressure, diabetes, a heart condition, or asthma, "X" could be a dangerous drug for you.

If you are suffering from depression, it may be best to avoid ecstasy as it may either aggravate or complicate the treatment of depression.

Antidepressants
  • MAO inhibitors (Nardil) should not be used in combination with "X" as mixing them might cause an increased blood pressure which could be life threatening. Do not mix!

  • Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and many others may have a reduced effect when mixed with "X." There is information to suggest that even short-term use of "X" may cause permanent changes in brain chemistry, which could increase the risk of depression.
GHB (G, Liquid Ecstasy)Protease inhibitors (PIs) may potentially increase levels of GHB in the bloodstream. This interaction is not well documented. However, there is a case report of a life-threatening reaction to GHB when given in combination with the PIs (ritonavir and saquinavir).GHB is difficult to measure since it is only available as a liquid. It is best to start with no more than one teaspoonful and wait about 30 minutes for effects to begin before taking more. In some people, effects can last for about 4 hours, depending on the dose and/or the possibility of drug interactions.

GHB overdoses can occur pretty quickly and may present with drowsiness, nausea, vomiting, headache, decreased breathing, loss of reflexes, and loss of consciousness. It is best to be on the buddy system when taking GHB.

Avoid mixing with alcohol and sedatives!

Alcohol and GHB are both central nervous system (CNS) depressants. When mixed together, alcohol can increase the potential for seizures, difficulty breathing, and GHB coma.
Sedatives (Valium, Halcion, Restoril, and many others) and GHB are both CNS depressants. When mixed together, they can increase your risk of GHB coma and breathing failure.
Heroin (Smack, Junk, China White)Protease inhibitors such as ritonavir may decrease heroin levels by 50%, thus decreasing the possibility of an overdose.Don't try to compensate for this possible interaction. Start with your normal dose and only increase if you experience a lesser effect.

Use clean and safe injection technique.

Heroin generally doesn't mix well with other party drugs so avoid mixing!

Ketamine (Special K, K, Vitamin K, Kitty Valium)Antiretrovirals such as protease inhibitors and delavirdine may increase the levels of "K" in the bloodstream, possibly leading to increased heart rate, increased blood pressure, or difficulty breathing.

A New York HIV doctor has reported two cases of "chemical hepatitis" that may be the result of mixing ritonavir with "K."

If mixing "K" with ARVs, less drug will go further. Start with 1/3 to 1/2 of your usual dose and wait for effect. Don't take another bump unless you feel OK. Otherwise, you may end up in a semi-conscious K-hole.

Avoid mixing with alcohol, GHB, or sedatives as all four can cause CNS depression.

Like GHB, it is best to be on the buddy system when taking "K."

Marijuana (THC)Protease inhibitors may increase levels of THC in the bloodstream. However, there are no known cases of marijuana overdose, so this interaction should not be dangerous.

Smoking marijuana may increase one's risk for pneumonia.

THC may be helpful to control nausea and to increase appetite. As an alternative to smoking, there is an oral form available (Marinol). Marinol may cause more tiredness and fatigue as compared to inhaled marijuana. If given with a protease inhibitor, Marinol can be introduced at a lower dose and increased for effect.
Sedatives (Benzodiazepines)Protease inhibitors may block the breakdown of certain sedatives, leading to increased blood levels of these drugs. Sedatives to avoid with P's include triazolam (Halcion), midazolam (Versed), flurazepam (Dalmane), and diazepam (Valium).Alternative sedatives that appear to be safer when combined with protease inhibitors include lorazepam (Ativan), temazepam (Restoril), oxazepam (Serax).

Avoid mixing with alcohol, GHB, or "K!"

Alcohol, GHB, and Ketamine are all CNS depressants and if mixed will increase the risk of decreased breathing or coma.
ViagraProtease inhibitors may decrease the clearance of Viagra, leading to high blood levels of Viagra. Side effects of interaction may include abnormal changes in blood pressure and chest pain.Recommended starting dose of Viagra is 25 mg. Dose may be increased if needed and/or tolerated.
Amyl Nitrate ("Poppers")
May result in extremely low blood pressure which can potentially be fatal.
Do not mix!


Please note that this is not a complete list of all drug interactions that occur with antiretrovirals or other HIV-related medications. The intention of this article is to focus on drug interactions that occur primarily with recreational drugs. If you have questions regarding drug interactions with other prescription and non-prescription medications or with recreational drugs not mentioned in this article, please consult your physician or pharmacist to ensure the safety of that combination. It is important that you feel comfortable talking to your healthcare provider without the fear of being judged.

Additionally, recommendations made to reduce the harm of certain combinations cannot be validated by studies, as there are none. There is no guarantee that a serious adverse reaction won't occur when combining certain drugs listed in the table above. It is important to accept the reality that people are mixing cocktails and party favors on a regular basis. It is simply the hope that after weighing the risks, you make an informed decision to choose what is best for you.

To further reduce the harm of mixing cocktails, here are some general guidelines:

  • If you are trying a recreational drug for the first time, try it alone, before mixing it with other substances.

  • Avoid mixing psychedelics with alcohol.

  • Be conservative and not greedy. Product batches are not always consistent. Just because you tolerated a dose this time, doesn't mean you won't overdose next time.

  • Realize that every person reacts differently. Just because your friend can tolerate a combination, doesn't mean that you can.

  • Party with friends who know what you are taking in case of an overdose.

  • Stay hydrated.

  • Get plenty of rest and let your immune system recover.

  • Antiretroviral therapy should not be interrupted, as interruption of therapy could lead to viral resistance. Talk to your doctor if you are thinking about stopping your medications.




  
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This article was provided by Seattle Treatment Education Project. It is a part of the publication STEP Perspective.
 
See Also
Ask Our Expert, David Fawcett, Ph.D., L.C.S.W., About Substance Use and HIV
More on Recreational Drug Use and HIV/AIDS

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