Drug and Alcohol Interactions - What to Avoid
You are probably familiar with the drug interaction warning labels that appear each time you pick up your prescription bottle. But how seriously do you take them? The Do Not Drink Alcohol label should be taken seriously to avoid the possibility of dangerous, or even deadly, drug interactions. You may be at risk, and not even know it.
This Drugs.com Alcohol Interaction series reviews multiple drugs classes and possible interactions with alcohol. Select specific classes of interest at the bottom of this article.
What happens when you mix alcohol with drugs? Since literally hundreds of medications can lead to alcohol (also called ethanol) interactions, it is important to review your medicines with your pharmacist or other health care provider to check for clinically significant drug-alcohol reactions. Even though some research suggests that moderate alcohol consumption is heart healthy, certain medications and alcohol have the capacity to interfere with your successful treatment.
Research has shown that the prevalence of alcohol and medication interactions is widespread.
- The National Institute of Health (NIH) conducted a study of over 26,000 adults from the National Health and Nutrition Examination Study (NHANES) to determine their alcohol and prescription drug use.
- They found that over 70% of U.S. adults regularly drink alcohol, and roughly 42% of those who drink also use medications that can interact with alcohol.
- Utilizing a large database of over 1,300 medications, they found that 45% of the medications had the potential to interact with alcohol.
Be sure to check on your prescription drugs, as well as your over-the-counter (OTC) medicines, herbals, and dietary supplements like vitamins and minerals. When combined with alcohol some OTC medicines can have serious drug interactions, too. However, do not stop using any medications without first talking to your doctor.
This might seem like a silly question, but it’s easy to forget that alcohol, while used socially for centuries, is a drug and can lead to side effects, drug interactions, alcoholism, and organ damage, such as cirrhosis of the liver. As reported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a report showed that annually there were over 78,000 liver disease deaths among individuals ages 12 and older, and 47% involved alcohol. Add chronic use of alcohol to the regular use of a medication that is hard on the liver, and the potential for harm can soar.
After nicotine, alcohol is the most commonly abused drug in our society. Why is alcohol a drug?
- Because it acts as a central nervous system depressant and has therapeutic uses in medicine, such as for nerve blocks for pain.
- Alcohol use elevates the inhibitory neurotransmitter gamma aminobutyric acid (GABA) and reduces nerves signals along this neuronal pathway.
- Because of this action, alcohol is known as a central nervous system (CNS) depressant, and lowers thinking, decision-making and memory skills as well as physical capacities.
Drug interactions may even occur with certain medicines that contain alcohol as an inactive ingredient, such as some cough and cold medicines you can buy OTC. Alcohol and cough syrup can compound each other's side effects like drowsiness. For example, the cough and cold medicine Vick's NyQuil Liquid contains 10% alcohol and can lead to a significant interaction. NyQuil LiquiCaps and Alcohol-Free NyQuil Cold & Flu Nighttime Relief Liquid do not contain alcohol.
Always review labels to look for interactions between allergy, cough and cold medicine and alcohol. Cough syrups often contain alcohol. Allergy medicine and alcohol can also magnify drowsiness. You can look at medicine labels to see what medicines have alcohol in them, or ask your pharmacist if there is a concern. Mixing these OTC medicines with alcohol may make driving hazardous. Alcohol is not a drug to take lightly.
According to a study conducted by the NIH looking at drugs and alcohol, the most common medications that interact with alcohol involve these drug classes:
- High blood pressure medication
- Sleeping pills (sedatives and hypnotics)
- Anxiety Medications
- Pain medications (analgesics)
- Skeletal muscle relaxants
- Diabetes medicine
- Cholesterol medications
Cardiovascular (heart) medications, central nervous system (CNS) agents like sedatives or narcotic pain relievers, and the metabolic class such as diabetes medicines were the most commonly used drug classes used by current drinkers in the study.
Blood pressure medicine and alcohol consumption is an interaction that should always be reviewed with a pharmacist, although many blood pressure meds and alcohol are safe to combine in moderation. Alcohol and blood pressure medication drug interactions may be taken for granted leading to hypotension (low blood pressure) in some cases.
The combination of painkillers and alcohol is also of great concern, and should always be avoided, considering the U.S. opioid epidemic. The use of alcohol and pain medications like narcotics together can slow breathing and may be fatal.
Drinking while taking steroids (corticosteroids, or anti-inflammatory medications like prednisone) often used for pain can lead to stomach bleeding and ulcers. NSAIDs like ibuprofen (Advil, Motrin) or naproxen (Aleve) and alcohol use can also cause stomach problems like ulcers.
Depression pills and alcohol can result in added drowsiness, dizziness and risk for injury. It is usually best to avoid the combination of alcohol and medications for depression. Ask your prescriber, as some antidepressants may increase drowsiness and make driving hazardous, especially if mixed with alcohol. Other types of interactions are possible, too.
The list of possible drug and alcohol interactions goes on, so being proactive in checking for interactions and discussing with your doctor or pharmacist is the best way to prevent harm.
Why is it dangerous to mix alcohol with drugs? When mixing alcohol and medications, various side effects that might occur include:
- Heart problems
- Bleeding, especially stomach
- Nausea and vomiting
- Low or high blood pressure
- Falls or injury due to accidents (such as a car accident)
- Liver or heart injury
- Slowed breathing (respiratory depression)
- Drug overdose
Drugs and alcohol use in seniors also poses a special concern, as older patients often take many medications that can interact with alcohol, including anticholinergic medications. Alcohol is not metabolized (broken down) as quickly in the older population, and their percent body water relative to fat is decreased, increasing the risk for complications.
The combination of alcohol and painkillers and other sedating medications may be a common risk for the elderly. Among adults over 65 years of age who were current drinkers in the NIH study, close to 78% of those surveyed used a medication that could interact with alcohol.
What are the effects of alcohol and drugs in the elderly?
- Additive effects of alcohol and medications on the central nervous system, for example, increased drowsiness, dizziness, confusion and risk for falls and injury.
- Risk for greater side effects due to enzyme interactions and increased or decreased levels of drug in the bloodstream. This can decreased the intended effect of the drug or cause side effects.
Alcohol and medication side effects may be especially prevalent in women. In fact, women may be at a greater risk of side effects due to alcohol and drug interactions than men. Women have a lower percent of body water and greater percent of body fat. Because of this, they do not metabolize alcohol as efficiently, putting them at greater risk for high blood alcohol levels after drinking the same amount of alcohol as a man. Add a drug, say a sedating drug to the mix, and the risk for dangerous side effects can skyrocket.
Children and Teens
Children, adolescents and young adults, while seemingly at lower risk for medicine interactions with alcohol, may still be of concern. Parents and clinicians should be alert for alcohol abuse in younger patients. This especially can be a risk when alcohol and ADHD medications such as the stimulants (for example: methylphenidate, Ritalin, Adderall) are combined.
Caffeine-fueled energy drinks can be a popular mix among college students. Energy drinks mixed with alcohol can lower the feeling of intoxication, which can lead to excessive drinking and alcohol-related injuries.
In your body, alcohol is primarily metabolized (broken down in the body for excretion) by two enzymes: alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH). ADH breaks down alcohol to acetaldehyde, a highly toxic and cancer causing agent, and then to the less active by-product called acetate, which is excreted as water and carbon dioxide.
Types of Drug Interactions With Alcohol
There are basically two types of drug interactions with alcohol.
- Pharmacodynamic Interactions
- When a medication side effect like drowsiness is magnified by the use of alcohol it is called an “additive” effect. These types of interactions are called pharmacodynamic interactions.
- They occur frequently when alcohol and pills that cause drowsiness are combined. For example, when alcohol is combined with some antihistamines, like diphenhydramine (Benadryl) that normally causes drowsiness as a side effect, the drowsiness may be magnified.
- This added drowsiness can interfere with the ability to concentrate, make reasonable judgement and can make driving or operating machinery hazardous.
- Pharmacokinetic Interactions
- These interactions occur when processes such as drug absorption, metabolism or excretion are changed.
- Alcohol is primarily broken down (metabolized) in the liver for excretion by various enzymes. Many medications are broken down by enzymes, too, so there can be competition in the body for these liver enzymes.
- These alcohol interactions can cause some medications to be less effective (by enzyme induction), or to build up causing toxic effects (by enzyme inhibition).
Alcohol and CYP Enzymes
Cytochrome P450 (CYP) enzymes are a group of enzymes found throughout the body, primarily in the liver. They help to break down drugs so they can be excreted from the body. There are many different types of enzymes with different names, indicated by letters and numbers.
Alcohol is metabolized by the CYP2E1 enzyme. One concern is that medications that are metabolized by the CYP2E1 can be affected.
- For example, the common pain and fever reliever acetaminophen (Tylenol) is also metabolized by CYP2E1. When alcohol and acetaminophen are combined in alcohol users that drink frequently each day, liver toxicity, and even liver failure, can occur, due to formation of dangerous acetaminophen by-products.
Alcohol is also known to strongly inhibit (or block) an enzyme in the liver known CYP2C9. When alcohol is consumed with other drugs that primarily use this enzyme for breakdown and excretion, blood levels of the other drug may theoretically increase, leading to increased side effects and toxicity.
- One example is the drug interaction between warfarin and alcohol, which could increase bleeding risk. Always check with your pharmacist to see if these types of enzyme interactions are of concern between your medications.
The use complementary medicine and herbal medicine has grown tremendously over the last few decades. A study by Ekors and colleagues noted that over 80% of people worldwide use some type of supplement. Many of these products are not regulated by authorities or monitored by a patient's healthcare provider, and the potential for drug interactions is often unknown. The use of alcohol with alternative medications should always be cleared with a provider first.
However, it is known that certain over-the-counter (OTC) medicines, dietary supplements, and herbal medicines can cause important interactions. It’s important to check for alcohol interactions with these groups just as you would with any other medication. Also, be sure to review your food and medicine labels to be sure these products do not contain alcohol or ethanol.
And remember, alcohol and medicines can have harmful interactions even if they are separated and taken at different times of the day.
- diazepam (Valium)
- alprazolam (Xanax)
- amphetamine and dextroamphetamine (Adderall)
- ibuprofen (Advil, Motrin)
- sertraline (Zoloft)
- metronidazole (Flagyl)
- azithromycin (Zithromax)
- diphenhydramine (Benadryl)
- escitalopram (Lexapro)
- tramadol (ConZip, Ultram)
- acetaminophen (Tylenol)
- fluoxetine (Prozac)
- acetaminophen and hydrocodone (Vicodin, Lorcet, Lortab)
- hydrocodone (Hysingla ER, Zohydro ER)
- metformin (Fortamet)
- doxycycline (Acticlate, Vibramycin)
- zolpidem (Ambien)
The lists presented in this review do not include all the medicines that may interact harmfully with alcohol. To more closely review specific interactions, visit the Drugs.com Interaction Checker and speak with your doctor or pharmacist.
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- Anticholinergic Drugs to Avoid in the Elderly
- Antibiotics and Birth Control Pill Interactions: Fact or Fallacy?
- Acne Medicines and Alcohol Interactions
- ADHD Medications and Alcohol
- Allergies, Cough/Cold Medications and Alcohol
- Antibiotic Medications and Alcohol
- Antidepressant Medications and Alcohol Interactions
- Antipsychotic Medications and Alcohol
- Anxiety Medications and Alcohol
- Bipolar Medications and Alcohol
- Birth Control Medications and Alcohol
- Blood Thinners and Alcohol: A Dangerous Mix?
- Caffeine, Energy Drinks and Alcohol
- Can You Mix Weight Loss Drugs and Alcohol?
- Cholesterol Medications and Alcohol
- Diabetes Medications and Alcohol
- Enlarged Prostate (BPH) Medications and Alcohol Interactions
- Erectile Dysfunction Medications and Alcohol
- Heart Medications and Alcohol
- Herbal Supplements and Alcohol
- Illicit Drugs and Alcohol Interactions
- Motion Sickness Drugs and Alcohol Interactions
- Muscle Relaxants and Alcohol Interactions
- Pain / Fever Drugs and Alcohol Interactions
- Seizure Medications and Alcohol Interactions
- Sleep (Insomnia) Medications and Alcohol
- Stomach / Heartburn Medications and Alcohol
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- National Center for Complementary and Integrative Health (NCCIH). US Dept. of Health and Human Services. Energy Drinks. Last updated Oct. 4, 2017. Accessed November 3, 2019 at https://nccih.nih.gov/health/energy-drinks
- Ekors M. The growing use of herbal medicines: issues relating to adverse reactions and challenges in monitoring safety. Front Pharmacol. 2013; 4: 177. Accessed Nov. 11, 2017.
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- Energy drinks: Do they really boost energy? Drugs.com. Accessed November 11, 2019 at https://www.drugs.com/mcf/energy-drinks-do-they-really-boost-energy
- Kids Should Not Consume Energy Drinks, and Rarely Need Sports Drinks, Says AAP. American Academy of Pediatrics (AAP). Accessed April 29, 2020 at https://healthychildren.org/English/news/Pages/Kids-Should-Not-Consume-Energy-Drinks-and-Rarely-Need-Sports-Drinks-Says-AAP.aspx
- Cherpitel CJ, Ye Y, Andreuccetti G, et al. Risk of injury from alcohol, marijuana and other drug use among emergency department patients. Drug Alcohol Depend. 2017 May 1;174:121-127. Accessed Nov. 7, 2019.
- Alcohol Facts & Statistics. National Institute on Alcohol and Abuse and Alcoholism (NIAAA). National Institutes of Health (NIH). Accessed Nov. 10, 2019 at https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics
- Davies M. The role of GABA-A receptors in mediating the effects of alcohol in the central nervous system. J Psychiatry Neurosci. 2003 Jul; 28(4): 263–274. Accessed Nov. 11, 2019.
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.