Alcohol-Medication Interactions
Many medications can interact with alcohol, leading to increased risk of illness, injury or death. For example, it is
estimated that alcohol-medication interactions may be a factor in at least 25 percent of all emergency room
admissions (1). An unknown number of less serious interactions may go unrecognized or unrecorded. This
Alcohol Alert notes some of the most significant alcohol-drug interactions. (Although alcohol can interact with illicit
drugs as well, the term "drugs" is used here to refer exclusively to medications, whether prescription
or nonprescription.)
How Common Are Alcohol-Drug Interactions?
More than 2,800 prescription drugs are available in the United States,
and physicians write 14 billion prescriptions annually; in addition,
approximately 2,000 medications are available without prescription (2).
Approximately 70 percent of the adult population consumes alcohol at
least occasionally, and 10 percent drink daily (3). About 60 percent of
men and 30 percent of women have had one or more adverse
alcohol-related life events (4). Together with the data on medication
use, these statistics suggest that some concurrent use of alcohol and
medications is inevitable.
The elderly may be especially likely to mix drugs and alcohol and are at particular risk for the adverse
consequences of such combinations. Although persons age 65 and older constitute only 12 percent of the
population, they consume 25 to 30 percent of all prescription medications (5). The elderly are more likely to
suffer medication side effects compared with younger persons, and these effects tend to be more severe with
advancing age (5). Among persons age 60 or older, 10 percent of those in the community - and 40 percent of
those in nursing homes - fulfill criteria for alcohol abuse (6).
How Alcohol and Drugs Interact
To exert its desired effect, a drug generally must travel through the bloodstream to its site of action, where it
produces some change in an organ or tissue. The drug's effects then diminish as it is processed (metabolized)
by enzymes and eliminated from the body. Alcohol behaves similarly, traveling through the bloodstream, acting
upon the brain to cause intoxication, and finally being metabolized and eliminated, principally by the liver. The
extent to which an administered dose of a drug reaches its site of action may be termed its availability. Alcohol
can influence the effectiveness of a drug by altering its availability. Typical alcohol-drug interactions include the
following (7): First, an acute dose of alcohol (a single drink or several drinks over several hours) may inhibit a
drug's metabolism by competing with the drug for the same set of metabolizing enzymes. This interaction
prolongs and enhances the drug's availability, potentially increasing the patient's risk of experiencing harmful
side effects from the drug. Second, in contrast, chronic (long-term) alcohol ingestion may activate
drug-metabolizing enzymes, thus decreasing the drug's availability and diminishing its effects. After these
enzymes have been activated, they remain so even in the absence of alcohol, affecting the metabolism of
certain drugs for several weeks after cessation of drinking (8). Thus, a recently abstinent chronic drinker may
need higher doses of medications than those required by nondrinkers to achieve therapeutic levels of certain
drugs. Third, enzymes activated by chronic alcohol consumption transform some drugs into toxic chemicals that
can damage the liver or other organs. Fourth, alcohol can magnify the inhibitory effects of sedative and narcotic
drugs at their sites of action in the brain. To add to the complexity of these interactions, some drugs affect the
metabolism of alcohol, thus altering its potential for intoxication and the adverse effects associated with alcohol
consumption (7).
Some Specific Interactions
Anesthetics. Anesthetics are administered prior to surgery to
render a patient unconscious and insensitive to pain. Chronic alcohol
consumption increases the dose of propofol (Diprivan)
1 required to
induce loss of consciousness (9). Chronic alcohol consumption
increases the risk of liver damage that may be caused by the
anesthetic gases enflurane (Ethrane) (10) and halothane
(Fluothane) (11).
Antibiotics. Antibiotics are used to treat infectious diseases. In
combination with acute alcohol consumption, some antibiotics may
cause nausea, vomiting, headache and possibly convulsions;
among these antibiotics are furazolidone (Furoxone), griseofulvin (Grisactin and others), metronidazole (Flagyl)
and the antimalarial quinacrine (Atabrine) (7). Isoniazid and rifampin are used together to treat tuberculosis, a
disease especially problematic among the elderly (12) and among homeless alcoholics (13). Acute alcohol
consumption decreases the availability of isoniazid in the bloodstream, whereas chronic alcohol use decreases
the availability of rifampin. In each case, the effectiveness of the medication may be reduced (7).
Anticoagulants. Warfarin (Coumadin) is prescribed to retard the blood's ability to clot. Acute alcohol
consumption enhances warfarin's availability, increasing the patient's risk for life-threatening hemorrhages (7).
Chronic alcohol consumption reduces warfarin's availability, lessening the patient's protection from the
consequences of blood-clotting disorders (7).
Antidepressants. Alcoholism and depression are frequently associated (14), leading to a high potential for
alcohol-antidepressant interactions. Alcohol increases the sedative effect of tricyclic antidepressants such as
amitriptyline (Elavil and others), impairing mental skills required for driving (15). Acute alcohol consumption
increases the availability of some tricyclics, potentially increasing their sedative effects (16); chronic alcohol
consumption appears to increase the availability of some tricyclics and to decrease the availability of others
(17, 18). The significance of these interactions is unclear. These chronic effects persist in recovering
alcoholics (17).
A chemical called tyramine, found in some beer and wine, interacts with some anti-depressants, such as
monoamine oxidase inhibitors, to produce a dangerous rise in blood pressure (7). As little as one standard drink
may create a risk that this interaction will occur.
Antidiabetic medications. Oral hypoglycemic drugs are prescribed to help lower blood sugar levels in some
patients with diabetes. Acute alcohol consumption prolongs, and chronic alcohol consumption decreases, the
availability of tolbutamide (Orinase). Alcohol also interacts with some drugs of this class to produce symptoms of
nausea and headache such as those described for metronidazole (see "Antibiotics") (7).
Antihistamines. Drugs such as diphenhydramine (Benadryl and others) are available without prescription to
treat allergic symptoms and insomnia. Alcohol may intensify the sedation caused by some antihistamines (15).
These drugs may cause excessive dizziness and sedation in older persons; the effects of combining alcohol and
antihistamines may therefore be especially significant in this population (19).
Antipsychotic medications. Drugs such as chlorpromazine (Thorazine) are used to diminish psychotic
symptoms such as delusions and hallucinations. Acute alcohol consumption increases the sedative effect of
these drugs (20), resulting in impaired coordination and potentially fatal breathing difficulties (7). The
combination of chronic alcohol ingestion and antipsychotic drugs may result in liver damage (21).
Antiseizure medications. These drugs are prescribed mainly to treat epilepsy. Acute alcohol consumption
increases the availability of phenytoin (Dilantin) and the risk of drug-related side effects. Chronic drinking may
decrease phenytoin availability, significantly reducing the patient's protection against epileptic seizures, even
during a period of abstinence (8, 22).
Antiulcer medications. The commonly prescribed antiulcer medications cimetidine (Tagamet) and ranitidine
(Zantac) increase the availability of a low dose of alcohol under some circumstances (23, 24). The clinical
significance of this finding is uncertain, since other studies have questioned such interaction at higher doses
of alcohol (25-27).
Cardiovascular medications. This class of drugs includes a wide variety of medications prescribed to treat
ailments of the heart and circulatory system. Acute alcohol consumption interacts with some of these drugs to
cause dizziness or fainting upon standing up. These drugs include nitroglycerin, used to treat angina, and
reserpine, methyldopa (Aldomet), hydralazine (Apresoline and others) and guanethidine (Ismelin and others),
used to treat high blood pressure. Chronic alcohol consumption decreases the availability of propranolol
(Inderal), used to treat high blood pressure (7), potentially reducing its therapeutic effect.
Narcotic pain relievers. These drugs are prescribed for moderate to severe pain. They include the opiates
morphine, codeine, propoxyphene (Darvon) and meperidine (Demerol). The combination of opiates and alcohol
enhances the sedative effect of both substances, increasing the risk of death from overdose (28). A single dose
of alcohol can increase the availability of propoxyphene (29), potentially increasing its sedative side effects.
Nonnarcotic pain relievers. Aspirin and similar nonprescription pain relievers are most commonly used by
the elderly (5) . Some of these drugs cause stomach bleeding and inhibit blood from clotting, alcohol can
exacerbate these effects (30). Older persons who mix alcoholic beverages with large doses of aspirin to
self-medicate for pain are therefore at particularly high risk for episodes of gastric bleeding (19). In addition,
aspirin may increase the availability of alcohol (31), heightening the effects of a given dose of alcohol.
Chronic alcohol ingestion activates enzymes that transform acetaminophen (Tylenol and others) into chemicals
that can cause liver damage, even when acetaminophen is used in standard therapeutic amounts (32, 33).
These effects may occur with as little as 2.6 grams of acetaminophen in persons consuming widely varying
amounts of alcohol (34).
Sedatives and hypnotics ("sleeping pills"). Benzodiazepines
such as diazepam (Valium) are generally prescribed to treat anxiety
and insomnia. Because of their greater safety margin, they have
largely replaced the barbiturates, now used mostly in the emergency
treatment of convulsions (2).
Doses of benzodiazepines that are excessively sedating may cause
severe drowsiness in the presence of alcohol (35), increasing the
risk of household and automotive accidents (15, 36). This may be
especially true in older people, who demonstrate an increased
response to these drugs (5, 19). Low doses of flurazepam (Dalmane)
interact with low doses of alcohol to impair driving ability, even when alcohol is ingested the morning after taking
Dalmane. Since alcoholics often suffer from anxiety and insomnia, and since many of them take morning drinks,
this interaction may be dangerous (37).
The benzodiazepine lorazepam (Ativan) is being increasingly used for its antianxiety and sedative effects. The
combination of alcohol and lorazepam may result in depressed heart and breathing functions; therefore,
lorazepam should not be administered to intoxicated patients (38).
Acute alcohol consumption increases the availability of barbiturates, prolonging their sedative effect. Chronic
alcohol consumption decreases barbiturate availability through enzyme activation (2). In addition, acute or
chronic alcohol consumption enhances the sedative effect of barbiturates at their site of action in the brain,
sometimes leading to coma or fatal respiratory depression (39).
Alcohol-Medication Interactions - A Commentary by NIAAA Director Enoch Gordis, M.D.
Individuals who drink alcoholic beverages should be aware that simultaneous use of alcohol and
medications - both prescribed and over-the-counter - has the potential to cause problems. For example, even
very small doses of alcohol probably should not be used with antihistamines and other medications with sedative
effects. Individuals who drink larger amounts of alcohol may run into problems when commonly used medications
(e.g., acetaminophen) are taken at the same time or even shortly after drinking has stopped. Elderly individuals
should be especially careful of these potential problems due to their generally greater reliance on multiple
medications and age-related changes in physiology.
1 The U.S. Government does not endorse or favor any specific commercial product (or commodity, service or
company). Trade or proprietary names appearing in this publication are used only because they are considered
essential in the context of the studies reported herein.
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