There hasn't been much research on how illegal street drugs and HIV medications interact. Certainly, your best bet is not to use street drugs at all if you're taking HIV medications. But some interactions are known to be more dangerous than others.
It's difficult to study interactions between illegal drugs and antiretrovirals. Some people have a higher tolerance to some drugs than other people do. Also, there are too many different kinds of cuts put on drugs, especially heroin and cocaine, which are hardly ever pure. So laboratory tests using pure heroin or cocaine, for example, wouldn't necessarily tell us what might happen in your body with drugs bought on the street.
We have more information about interactions with prescription drugs that are used recreationally, But even then, some drugs that are available by prescription, when bought on the street, may be cut with other substances that could cause unexpected interactions with other drugs.
- Videx (ddI) can increase the risk of pancreatitis, and so can chronic alcohol use. So if you're using alcohol regularly, inform your healthcare provider and consider alternatives to Videx. There are other nucleosides to choose from.
- Alcohol increases Ziagen (abacavir) levels in your blood. A small study showed that consuming the equivalent of five alcoholic drinks with Ziagen resulted in up to a 41% increase in Ziagen levels. The increase isn't a good thing. Regular Ziagen dosing (300 mg every 12 hours) gives you enough of the drug to do the job. Increasing the amount won't fight HIV any better -- but it could increase your risk of side effects. Ziagen is also in the combination pills Trizivir and Epzicom.
- Alcohol should not be used with Agenerase (amprenavir) oral solution (the liquid version) because it has propylene glycol in it, which can cause side effects when it's mixed with alcohol.
- The protease inhibitor Reyataz (atazanavir) can increase levels of bilirubin in some people, which can cause jaundice (yellowing of the skin and whites of the eyes). If you start taking Reyataz, be sure to have liver function tests performed regularly, including checking bilirubin levels. People with liver disease, such as chronic hepatitis B or hepatitis C, or liver damage caused by alcohol use may be more likely to experience high bilirubin levels, but no differences have been reported so far in people with mild to moderate liver damage.
- Occasional and light use of alcohol is not known to interact with other HIV medications, but regular, heavy alcohol use can damage your liver, which might make it more difficult for your liver to properly break down some anti-HIV drugs, particularly protease inhibitors and non-nucleosides. The result could be levels of these antiretrovirals that are too low to slow down HIV replication the way they're supposed to. That could result in a higher viral load, lower CD4 count, and the development of drug-resistant HIV. Liver damage can also work the opposite way, allowing some drugs to build up in your system, which could cause worse side effects or an overdose.
- Since alcohol can cause dehydration, be sure to drink a lot of water to help your body deal better with any alcohol you drink.
Amphetamines (Speed, Methamphetamine, Crystal Meth [Tina, Ice])
- Norvir (ritonavir) -- at full dose or the much lower doses used to "boost" other protease inhibitors -- could increase amphetamine levels in the blood significantly. Kaletra, which contains a small amount of ritonavir, could have the same effect. This increase isn't a good thing. It could have serious consequences, including a faster heart rate and higher blood pressure, possibly even death. The other protease inhibitors and the rarely used non-nucleoside Rescriptor (delavirdine) could have less of an impact, but might still have some. There's no sure way to predict what might happen with these combinations.
- Taking amphetamines and certain antidepressants called SSRIs (Prozac, Paxil, Luvox, or Zoloft) together could, at least hypothetically, lead to a condition called "serotonin syndrome," which can be life-threatening. When serotonin levels increase too much, confusion, agitation, coma, anxiety, and seizures can occur.
Cocaine (Coke, Blow, Crack)
- There have been no reported interactions between cocaine and HIV medications.
- You may have heard reports that cocaine significantly speeds up HIV reproduction in lab cultures. There have also been studies showing that mice infected with HIV and then injected with cocaine had significantly more virus and fewer CD4 cells than mice infected with HIV but no cocaine. This could certainly mean that cocaine use speeds up HIV disease progression in people, although what actually happens in the human body isn't clear.
Ecstasy (MDMA, X)
- There was one death in England, which resulted from a single dose of Ecstasy taken with Norvir. Norvir slows down the liver enzyme that breaks down Ecstasy, so Ecstasy accumulates in your system, making it 5 to 10 times stronger. In addition, up to 10% of Caucasians (the figure for other populations isn't known) have a deficiency in this enzyme, which may be why some people could overdose on what would be a non-toxic dose for others. If you're taking any protease inhibitor or non-nucleoside, Ecstasy can be extremely dangerous. Of these, Norvir seems to be the most dangerous, while Viracept (nelfinavir), Viramune (nevirapine), and Sustiva (efavirenz) may be less so. But drug interactions in the test tube are sometimes opposite to those seen in the body, so, again, this is hard to predict.
- If you do take Ecstasy with a protease inhibitor, wait as long as possible after taking the medication before taking the Ecstasy. And be sure to have someone with you who knows what you've done in case you have difficulties. It's really better not to mix these drugs! If you do, think about taking less Ecstasy than you might normally take -- maybe 25% of your usual amount. Be sure to take regular breaks from dancing and other physical activity, drink plenty of fluids, and avoid alcohol -- alcohol causes dehydration.
- If you aren't dancing or exercising, however, don't drink large quantities of water after taking ecstasy. It's actually possible to fatally overdose on water this way, because Ecstasy can also slow the body's ability to expel water as urine. Basically, drink to quench your thirst.
GHB (Gamma-Hydroxy-Butyrate, Grievous Bodily Harm, Liquid X, G)
- GHB is potentially dangerous with protease inhibitors, especially Norvir (full dose or lower doses), as well as the non-nucleosides Rescriptor and, possibly, Sustiva. And never mix GHB with alcohol.
Heroin (Dope, Smack, Brown, Junk, China White)
- Some people who use heroin and are prescribed antiretrovirals for their HIV may be afraid to take their HIV medications regularly for fear that they'll interact with the heroin. There are no documented interactions between antiretrovirals and heroin, although there are some theoretical ones. If you're using heroin, it's probably fine -- and better for your health -- to take your anti-HIV medications as well.
- Most protease inhibitors -- Norvir, Kaletra, Agenerase, Lexiva, and Viracept in particular -- as well as the non-nucleosides Rescriptor and Sustiva may reduce heroin levels, although this is only based on theoretical research about the way your body breaks down heroin and these particular drugs. If this is true, it could lead to withdrawal symptoms. You might need more frequent doses of heroin to avoid withdrawal -- one big dose won't last longer and could be an overdose. Be careful.
- Some synthetics sold as heroin (fentanyl, alpha-methyl-fentanyl) are potent in tiny doses and could be deadly if combined with another drug.
Ketamine (Special K)
- When combined with some anti-HIV medications, Special K can lead to "chemical hepatitis," inflammation of the liver that could require hospitalization. The inflammation usually goes away in several weeks, but anything that damages the liver can be a serious problem for people with HIV. Norvir, Kaletra, Viracept, Agenerase, Lexiva, Rescriptor, and Sustiva are the antiretrovirals with the greatest potential to cause ketamine toxicity.
LSD (Acid, Blotter)
- No known interactions. But it's possible that some anti-HIV medications, especially Norvir, could lead to a longer or more intense trip than planned or desired.
- According to one study, smoked marijuana slightly lowers levels of the protease inhibitors Crixivan and Viracept, although the decreased levels weren't enough to affect the antiretrovirals' activity. Protease inhibitors may also increase THC levels, the active ingredient in marijuana -- so smaller doses may make you more stoned. The same is true of the synthetic version, Marinol (dronabinol), which contains THC and is used to treat nausea and increase appetite. This interaction doesn't seem to be dangerous -- although you should consider it if you're planning on being coherent!
- Sustiva makes many people feel at least somewhat disoriented. Using marijuana might heighten these feelings -- and not necessarily in a good way.
PCP (Angel Dust, Rocket Fuel)
- Levels of PCP may increase due to interactions with protease inhibitors or the non-nucleosides, Rescriptor and, possibly, Sustiva. These interactions could cause PCP toxicity. If you're on anti-HIV medications and using PCP, think about using less PCP than you might otherwise to avoid a possible interaction.
Poppers (Amyl Nitrate or Butyl Nitrate)
- Be sure not to use poppers if you take Viagra, Levitra, or Cialis. Poppers increase levels of these drugs, lowering your blood pressure enough to cause serious, even lethal, reactions (see below for more detail).
- There are no known interactions between Ritalin and any medications specific to HIV.
Sedatives and Tranquilizers
- Interactions between barbiturates, benzodiazepines and antiretrovirals, especially the protease inhibitors and non-nucleosides, are tricky. There are many possible variables that could affect the interactions listed below, including other drugs that you might be taking.
Barbiturates (Barbs, Downers)
- Barbiturates are rarely used on the street since they don't provide much of an attractive high or down. But if you are taking barbiturates, there are some things that could be helpful to know:
- Combining a barbiturate -- Amytal (amobarbital), Nembutal (pentobarbital), or Seconal (secobarbital), for example -- with many of the protease inhibitors or non-nucleosides can lower levels of the anti-HIV medication. This interaction can reduce or eliminate the benefit of the anti-HIV drug and possibly cause HIV to develop resistance to the drug.
- High doses of barbiturates can cause unconsciousness, even death.
- The combination of barbiturates with alcohol or any other central nervous system depressant, including heroin, is extremely dangerous. Alcohol intensifies the sedative effect of the barbiturate, which can cause abnormally slow and shallow breathing, coma, and death. Even the normal dose of a barbiturate can be lethal if it's combined with alcohol.
Benzodiazepines (Bennies, Benzos, Downers)
- Taking the sedatives Halcion (triazolam) or Versed (midazolam) with any of the available protease inhibitors or the non-nucleosides Rescriptor or Sustiva could lead to a very dangerous, even deadly interaction, raising Halcion or Versed levels so much that serious sedation could result, possibly stopping your breathing.
- Taking Ambien (zolpidem) with full-dose Norvir could cause a similar reaction, but low-dose Norvir, which is usually prescribed now, doesn't seem to significantly increase Ambien levels.
- Valium (diazepam) and Tranxene (clorazepate) levels can also increase when used with some of these same anti-HIV medications -- particularly Invirase, Fortovase, Norvir, Agenerase, and Lexiva -- but the interaction doesn't seem to be as severe or as potentially dangerous as that of Halcion or Versed.
- Norvir may increase Klonopin (clonazepam) levels, while Viramune and Sustiva may decrease Klonopin levels, possibly leading to symptoms of benzodiazepine withdrawal.
- Norvir slightly decreases Xanax (alprazolam) levels, while Invirase, Fortovase, Agenerase, Lexiva and Rescriptor increase Xanax levels. Except for Rescriptor, which greatly increases Xanax levels, the degree that these other antiretrovirals raise Xanax levels isn't clear.
- Invirase, Fortovase, Agenerase, Lexiva and Rescriptor may increase Dalmane (flurazepam) levels as well, but not as significantly as with Halcion or Versed.
- Physical dependence on benzos can develop. Withdrawal should be medically supervised because of the risk of seizures.
- Combining benzodiazepines with alcohol can be life threatening. Alcohol intensifies the sedative effect of the benzodiazepam, which can lead to coma or death. Benzos can also interact with opiates such as heroin, methadone or OxyContin (oxycodone) to cause increased, possibly lethal sedation.
Bottom line: Mixing downs can be very dangerous. Mixing depressant drugs -- alcohol and opioids; alcohol and barbiturates; alcohol and benzodiazepines; or a combination of depressant drugs -- is the cause of most overdose deaths.
Viagra (Sildenafil), Levitra (Vardenafil), and Cialis (Tadalafil)
- These three drugs, marketed to help with impotence (erectile dysfunction), are often used recreationally by men to help get and keep an erection. None of them increase sexual desire. Although these are prescription drugs, people often get them through friends, on the street, or through the Internet. This means that what looks like Viagra, for example, may be Viagra -- then again, it may not be. The three available medications have similar interactions with other drugs.
- There has been at least one documented death caused by the interaction of a protease inhibitor and Viagra (sometimes called blue diamonds or Vitamin V). The man had a heart attack. Protease inhibitors increase the blood concentrations of Viagra, which raises the likelihood and severity of side effects -- extremely low blood pressure, dizziness, fainting, changes in your vision, and prolonged erection (meaning hours -- not a good thing). Norvir (ritonavir) increases Viagra concentrations the most, while Fortovase (soft-gel saquinavir) and Invirase (hard-gel saquinavir) seem to have the least effect on Viagra blood levels. Other medications that increase Viagra blood levels include the non-nucleoside Rescriptor, the antifungals Nizoral (ketoconazole) and Sporanox (itraconazole), and the antibiotic erythromycin.
- Levitra and Cialis have similar interactions with these same drugs. Although not every drug has been studied with each of these medications to figure out every conceivable interaction, the way that they're broken down by the liver gives us a good idea of the possible interactions.
- The usual dose of Viagra is 50 mg once a day (at most). The usual dose of both Levitra and Cialis is 10 mg, also once a day at most. Based on what's known and what can be assumed, take a lower dose of Viagra, Levitra, or Cialis -- and take it less often -- to avoid a possibly dangerous drug interaction if you're also taking one of the drugs listed above. Some examples:
If you're on a protease inhibitor, don't take more than one 25 mg dose of Viagra within a two-day period.
If you're on a protease inhibitor-containing regimen that doesn't include Norvir, the highest dose of Levitra should be 2.5 mg within a 24-hour period.
If you're taking Kaletra or Norvir (even at a low dose) as part of your regimen, the highest dose of Levitra should be 2.5 mg and it shouldn't be taken again for three days.
If you're taking erythromycin, don't take more than one 5 mg dose of Levitra in a 24-hour period.
If you're taking 200 mg of Nizoral a day, your dose of Levitra shouldn't be more than 5 mg in one day; and if you're taking 400 mg of Nizoral a day, your dose of Levitra shouldn't be more than 2.5 mg in one day.
If you're taking Norvir (including low-dose Norvir), Nizoral, or Sporanox, your dose of Cialis should be 10 mg no more than once in three days.
Grapefruit juice could increase levels of Cialis in your blood, so avoid it if you take that drug.
Levitra can decrease levels of the protease inhibitor Crixivan, so if you're taking Crixivan three times a day (which is rare), it would be safer to use Viagra or Cialis at lower doses than usually recommended.
- Using poppers (amyl nitrate or butyl nitrate) with Viagra, Levitra, or Cialis can cause a severe decrease in blood pressure -- low enough to cause you to fall down or faint, perhaps hurting yourself. Even more serious reactions due to the drop in blood pressure include stroke, heart attack, and death.
- If you take one of these drugs and have an erection that lasts for more than four hours, go to the emergency room. If you don't get treated, this can result in the permanent loss of erectile function.
- Combining Cialis with significant amounts of alcohol can increase the side effects of Cialis, perhaps to a dangerous degree. Combining alcohol with Viagra or Levitra doesn't seem to have the same effect.
- If you have liver damage due to viral hepatitis, alcohol use, or for any other reason, be careful if you use any of these drugs. If you have mild to moderate liver damage, use a low dose (25 mg of Viagra, 5-10 mg of Levitra, or no more than 10 mg of Cialis). Higher doses could cause serious side effects. We don't know what happens if someone with severe liver damage takes one of these drugs. If you're on a protease inhibitor and have liver damage, your safest bet is not to use them at all -- in that situation, there would be a lot going on at once and unpredictable things could happen.
- If you have kidney damage and plan to use one of these drugs, either take Levitra (which kidney damage doesn't seem to affect) or a low dose of Viagra (25 mg) or Cialis (5 mg).
Levitra and Cialis are relatively new compared to Viagra, which has been on the market since 1998. As more people use these drugs and further studies are conducted, we'll learn more about their safety and other possible interactions.