Interaction of Street Drugs with HIV Medications

Prepared by Mark Kinzly

Interaction of Street Drugs with HIV Medications Prepared by Mark Kinzly CIRA Yale School of Public Health

UNDERSTANDING DRUG USE LETS EXPLORE SOME OF THE PREDUDICES WE SHARE ABOUT DRUG USE AND DRUG USERS AND HOW THESE PARTICULAR PREDUDICES PLAY A ROLE IN HOW WE DEAL WITH THE ISSUE. Prepared by Mark Kinzly

BASIC DEFINITION OF A DRUG • “A common definition of the word ‘drug’ is any substance that in small amounts produces significant changes in the body, mind or both.” --Andrew Weil, M.D. Prepared by Mark Kinzly

Religious Practices Boredom Despair Treat disease Social interaction Artistic Enlightenment Escape Relaxation WHY DO PEOPLE USE DRUGS? Prepared by Mark Kinzly

WHY DO PEOPLE USE DRUGS? • Coping with sexual abuse • Cope with pain—physical and emotional • For courage • To feel safe • To feel a sense of freedom • Feel powerful • Take part in other activities Prepared by Mark Kinzly

DRUG SET SETTING Prepared by Mark Kinzly

DRUG, SET AND SETTING • DRUG: Pharmacology • SET: Individual drug user • SETTING: Contexts of drug use Prepared by Mark Kinzly

CONTINUUM OF DRUG USE NO USE OCCASIONAL HEAVY -------------------------------------- EXPERIMENTAL REGULAR CHAOTIC Prepared by Mark Kinzly

CONTINUUM OF DRUG USE • NO USE: Is defined differently by different communities and constituencies. To some it means using no illegal drugs, but legal ones may be used. When the term “abstinence” is used , it is often applied to young people. This is when the term most commonly implies abstinence from both illegal and legal substances such as alcohol and cigarettes. Prepared by Mark Kinzly

CONTINUUM OF DRUG USE • EXPERIMENTAL: Is the starting point for most people who have used drugs. Almost half of all high school students have tried illegal drugs, and more than 70% have tried alcohol (also illegal in their case). Experimentation with drugs is a familiar part of adolescence for many people. Prepared by Mark Kinzly

CONTINUUM OF DRUG USE • OCCASIONAL: Is the way that most people in our society use drugs. This periodic use is often related to social occasions. Prepared by Mark Kinzly

CONTINUUM OF DRUG USE • REGULAR: Marks an increase in the frequency of drug taking; the drug use starts to become an expected part of a persons life. A persons use may change from “recreational” and become a coping mechanism. • RISK: • * Creating a physical dependency • *Replacing existing coping mechanism with external one Prepared by Mark Kinzly

CONTINUUM OF DRUG USE • HEAVY: Means the use of drugs on a daily basis or multiple times a day. At this point a person’s life beginning to be organized around the drug. • RISKS: *Increased physical dependency to the drug *Increased chances of contact with law enforcement *Increased health problems Prepared by Mark Kinzly

CONTINUUM OF DRUG USE ---------------------------------------------- NO USE CHAOTIC ---------------------------------------------- LOW RISK HIGH RISK Prepared by Mark Kinzly

CONTINUUM OF DRUG USE TREATMENT AND POLICY Most US drug prevention, treatment, and policy decisions are based on a perception of drug use as chaotic, chronic and pathological. This approach only deals with the right end of the continuum. Most drug users do not fall into this end of the continuum. Prepared by Mark Kinzly

STAGES OF CHANGE • PRECONTEMPLATION:PERSON IS UNAWARE OR NOT CONCERNED ABOUT CONSUMPTION PATTERNS OR NEED FOR CHANGE • CONTEMPLATION: PERSON IS AWARE OF THE PROBLEM AND IS CONSIDERING WHETHER OR NOT A CHANGE IS NEEDED • PREPARATION: PERSON BEGINS TO THINK ABOUT HOW TO MAKE A CHANGE OR TAKE STEPS TOWARD CHANGE Prepared by Mark Kinzly

STAGES OF CHANGE • ACTION: PERSON MODIFIES HIS/HER BEHAVIOR, EXPERIENCES AND/OR ENVIORNMENT IN ORDER TO OVERCOME HIS/HER PROBLEMS • MAINTENANCE: (INCLUDING RELAPSE) A CONTINUATION OF THE CHANGE PROCESS Prepared by Mark Kinzly

SUPPORT ADHERENCE • Many current and former drug users can adhere to the complex and difficult therapies-experienced with HIV treatment. It’s not always easy to predict who will have problems adhering to treatment. A simple way to gauge adherence is to access whether people can consistently keep medical appointments. If someone’s able to make 3 consecutive appointments, even if Prepared by Mark Kinzly

SUPPORT ADHERENCE • h/she has to reschedule, then h/she’s more likely to be able to adhere to treatment. People who routinely miss medical appointments might need more support or stability in their lives before embarking on treatment. Talk to your folks about what’s going on, and how you can help them achieve their goals. Prepared by Mark Kinzly

DRUGS AND THE BODY • Lets make to mistakes about it. Drugs and drug use whether it be because of the substance/cut itself or because of some of the behaviors and life styles that come with it can have a negative affect on the ability for the HIV meds to work to their fullest. Prepared by Mark Kinzly

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 Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly 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. Prepared by Mark Kinzly

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. Ocassional or light use has not shown to have great affects on HIV Meds. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

Barbiturates • Crixivan may increase blood levels of phenobarbital (Luminal), making overdose more likely. Other protease inhibitor interactions are also possible. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

Ritalin • Norvir and other similar drugs can either strengthen Ritalin's effects or make it weaker. Beware! Prepared by Mark Kinzly

GHB,Liquid X • GHB is potentially dangerous with Norvir and other protease inhibitors. • One man had serious life-threatening 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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

Ketamine (Special K) • When combined with Norvir, special K can lead to "chemical hepatitis," an unpleasant inflammation of the liverresulting 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. Prepared by Mark Kinzly

LSD (acid, blotters) • No known interactions. Prepared by Mark Kinzly

Mushrooms(shrooms, boomers, psilocybin) • No known interactions. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

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. Prepared by Mark Kinzly

Interaction of Street Drugs with HIV Medications