Meds, Drugs and HIV

Questions and answers on the dangers of mixing HIV medications and recreational drugs, by Wendy Zizzo, Pharm.D., Haight Ashbury Free Clinics, Drug Detoxification, Rehabilitation and Aftercare program.

How do recreational drugs interact with HIV prescription medications such as anti-retrovirals?

Interactions between recreational drugs and anti-retrovirals have not been scientifically studied. Based on anecdotal reports and what we know about the metabolism of these drugs, we believe that harmful drug interactions may occur, especially with the group of anti-retrovirals known as protease inhibitors. The liver is the primary organ involved in the metabolism of these drugs. If two or more drugs are present in the body at the same time, the liver can become so busy metabolizing one drug that metabolism of the second drug is delayed. Protease inhibitors, especially Ritonavir®, can inhibit the metabolism of some recreational drugs, resulting in increased recreational drug levels, possibly to harmful or fatal (toxic) levels.

Which recreational drugs are likely to interact with protease inhibitors? Will protease inhibitors increase or decrease the “high” or produce unexpected effects from taking recreational drugs?

Some possible interactions of recreational drugs with protease inhibitors are listed below. While specific interactions are unknown, it is more likely that protease inhibitors will increase the potency of recreational drugs, resulting in an increased “high,” more side effects and possible overdose. Keep in mind that there are a number of different protease inhibitors and that each may interact differently. Of the protease inhibitors currently on the market, Ritonavir® is the most potent inhibitor of liver metabolism, and is therefore more likely to affect the potency of the recreational drug.

Have there been reports of harmful interactions between recreational drugs and protease inhibitors? Can I die from an interaction?

Yes, one fatality that was reported in Great Britain apparently resulted from combining the recreational drug Ecstasy (X, MDMA) with the protease inhibitor Ritonavir®. Drug interactions are harmful or fatal if recreational drug levels reach toxic concentrations.

If I use recreational drugs and take protease inhibitors, is there anything that I can do to avoid harmful drug interactions?

Some people who are taking protease inhibitors make the decision to use recreational drugs even while knowing the risks involved. Before making this decision, individuals should be informed of the potential for increased drug potency and the possible increased toxicity of the recreational drug. You can expect that combining protease inhibitors and some recreational drugs (see chart) will significantly increase the potency of these recreational drugs. Therefore, people intent on using recreational drugs may need to decrease their intake of the recreational drug below the amount they would normally require (if they were not taking a protease inhibitor), to obtain the same “high” or expected recreational drug effects and avoid overdosing. There are no set guidelines for how much the dosage of these recreational drugs should be reduced; therefore, recreational drug users must exercise caution. It is often also important to drink adequate amounts of water or other non-alcohol fluids when using some recreational drugs, to avoid dehydration.

Is there an alternate HIV medications regimen that does not include protease inhibitors, which will not cause interactions with recreational drugs?

An option for people committed to using recreational drugs is to re-evaluate with your physician or primary care provider whether this is the right time in your life for taking protease inhibitors. There are alternative anti-retroviral regimens for people who cannot adhere to or are not ready for protease inhibitor regimens. However, other anti-retroviral drugs may have harmful interactions with recreational drugs as well. For example, the anti-retroviral ddI in combination with alcohol can cause potentially fatal pancreatitis.

Will using recreational drugs decrease the effectiveness of protease inhibitors?

It is unknown if recreational drug use directly decreases the efficacy of protease inhibitors. It is known that recreational drug use often impairs an individual’s immune system. The lifestyle that sometimes accompanies recreational drug use (such as poor nutrition, lack of sleep, failure to keep medical appointments) may decrease an individual’s ability to stick to a schedule for taking prescription medications (strictly adhere to a protease inhibitor regimen), which also decreases overall anti-viral effectiveness and could lead to viral resistance. Recreational drug usage can also decrease inhibitions and cloud judgment, which may increase your potential for high-risk behaviors.

Should I temporarily stop taking my protease inhibitors when I am going to use a recreational drug, to avoid a potential harmful drug interaction?

Protease inhibitor therapy should not be interrupted, unless recommended by your physician or primary care provider. Interruption of protease inhibitor therapy could lead to the development of viral resistance.

Who can I talk to if I would like to obtain additional information about potential interactions between protease inhibitors and recreational drugs?

Consult with your physician or primary care provider.

What should I do if I think I am suffering an adverse drug interaction?

If you believe you are having an interaction, you should seek medical help immediately.

Author: Wendy Zizzo, Pharm.D., Haight Ashbury Free Clinics, Drug Detoxification, Rehabilitation and Aftercare program.
Originally published: 30 June 2003
Revised: N/A