Recreational Drugs, Methadone and Protease Inhibitors
Do protease inhibitors make heroin stronger or weaker? Every day brings a variety of questions to the Treatment Education Project, an initiative of the Staten Island AIDS Task Force. A common request is for information about protease inhibitors, street drugs, and methadone. From time to time, someone has a bad drug reaction, and word-of-mouth spreads anecdotal information. Last spring, a PWA died from using a combination of Ecstasy and Ritonavir.
To date, researchers have avoided this topic for a number of reasons. Why? First of all, they would need access to a consistent supply of the drugs to be studied so all the study participants would get drugs of the same amount and purity. Second, because these drugs are illegal, they would need to get special licenses from the federal government to use them in the study, and it's not likely that they would receive them. A study of drug interactions can't be based on heroin bought on a street corner. Too often, the purity of drugs is compromised by being cut with something else. In addition, the amount of the drug may vary from purchase to purchase. Finally, in the event that the federal government sanctioned a study and provided pharmaceutically pure heroin to run it, the results would not be useful to people who are actively using because they are not using pharmaceutically pure heroin.
What About Methadone?
Methadone is a legal, controlled substance manufactured to be pure and given in the same amount in each dose. Because many people with HIV take it daily, it is important to know just how methadone interacts with HIV drugs. Some studies have been conducted documenting methadone's interaction with rifampin (it decreased methadone concentration by 33%-93%) and fluconazole/diflucan (it increased methadone concentration by 30%).
How does methadone interact with protease inhibitors? Abbott Laboratories recently reported a small but important study (11 people -- seven men and four women) on the effects of methadone when taken with their protease inhibitor ritonavir (Norvir). Prior to beginning the study, their theoretical models were predicting that ritonavir would increase methadone levels by as much as 300%. What they found was the opposite: methadone was decreased by 36%.
There are some other important things to know about the Abbott study. First of all, it was very small, and the participants were HIV-negative, healthy people, presumably with no history of drug use. Their first dose of methadone (20 mg) came on the first day of the study, and then their bodies were monitored to see how fast they metabolized methadone without ritonavir. Then they were given ritonavir from days 15-28 of the study (it takes awhile for your body to build up enough ritonavir). On day 25 the participants were given their second dose of methadone (5 mg). Then for the next three days the methadone and ritonavir levels in their blood were monitored.
Some obvious questions include: Why only two (small) doses of methadone 25 days apart? Many people take much larger doses daily for years. How could their bodies be different? What about liver damage, or elevated liver enzymes from years of drug/alcohol use?
And Now A Word About Marijuana
For years the debate has raged between users of Marinol and marijuana about which is better. Now, this debate is moving to the next level: What are the interactions of each drug with Crixivan? The Community Consortium, a group of physician-scientists at the University of California/San Francisco, have announced a two-year study on the effects of Marinol, marijuana, or a placebo on people with HIV. The participants in all three arms of the study will also be using Crixivan. In addition to the effect of these drugs on the body's ability to use Crixivan, they will also be studying the effect of Marinol and marijuana on weight gain or loss, increase in appetite, the immune system, viral load, and hormone levels -- especially testosterone. The federal government is supplying the marijuana for the study. If you want more information, or want to enroll, call Alice Trinkl at UC/San Francisco (415-476-3804).
These are only a few of the questions we get at the Treatment Education Project. In addition, we clarify complex medical information, and bring the most recent medical developments to Staten Islanders living with HIV, their friends, family, and social service providers. We provide individual counseling, telephone counseling, and two Internet access computers for clients (in English and Spanish). We are in the midst of setting up treatment libraries at Camelot Counseling, the COPE Program in Arthur Kill Prison, Project BUILD, Project Hospitality, the Society for Children and Families, and at the Task Force offices in Port Richmond and St. George. We also provide free HIV training workshops about drugs, treatments, and HIV in social service agencies for clients and staff. If you would like more information about our services, call us at (718) 448-8802, and ask for Karin or Lorraine.