Drug and Alcohol Interaction Guidelines
Medically reviewed on Nov 11, 2017 by L. Anderson, PharmD.
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 known it.
This Drugs.com Alcohol Interaction series reviews multiple drugs classes and possible interactions with alcohol. Select classes of interest at the bottom of this article.
What Medication Can You NOT Drink Alcohol With?
What happens when you mix alcohol with drugs? That’s the big question. Since literally hundreds of medications can lead to alcohol (ethanol) interactions, it is important to review your medicines and speak with your pharmacist or other health care provider to check for clinically significant drug-alcohol reaction any time you start a new medicine. Even though some research suggests that moderate alcohol consumption is heart healthy, certain medications and alcohol have the capacity to interfere with your successful drug therapy.
Research has shown that the prevalence of alcohol and medication interactions is widespread. In 2015, Breslow and colleagues at 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 (591) had the potential to interact with alcohol. It seems reasonable to expect that medication and alcohol interactions may be as prevalent in 2017.
Be sure to check on your prescription drugs, as well as your over-the-counter (OTC) medicines, herbals, and dietary supplements like vitamins. When combined with alcohol some over the counter drugs can have serious interactions, too. However, do not stop using any medications without first talking to your doctor.
Is Alcohol a Drug?
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, and end organ damage, such as cirrhosis of the liver. In fact, in 2015, there were over 78,000 liver disease deaths among individuals ages 12 and older, and 47% involved alcohol, according to the National Institute on Alcohol and Abuse and Alcoholism (NIAAA). Add chronic use of alcohol to regular use of a medication that is hard on the liver, and the potential for harm can soar.
Why is alcohol a drug? Because it acts as a central nervous system depressant but does have some therapeutic use in medicine, such as for nerve blocks for pain. Alcohol used systemically, as in drinking, elevates the inhibitory neurotransmitter GABA (gamma amino butyric acid) and reduces nerves signals along that neuronal pathway. Because of this action, alcohol is known as a central nervous system (CNS) depressant, and lowers both cognitive and physical capacities. Alcohol is the most commonly abused drug in our society.
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, Vick's NyQuil Liquid contains 10% alcohol; alcohol and cold medicines can be a significant interaction.
Always review labels to look for interactions between cold medicine and alcohol, and cough syrup and alcohol. Mixing cold medicine with alcohol may make driving hazardous. 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. Alcohol is not a drug to take lightly.
Drug Interactions With Alcohol
According to a study conducted by the NIH looking at drugs and alcohol, the most common medications that interacted with alcohol involved these drug classes:
- High blood pressure medication and alcohol
- Sleeping pills (sedatives and hypnotics) and Anxiety Medication
- 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 disrupt breathing and may be fatal.
Drinking on steroids (corticosteroids, or antiinflammatory medications like prednisone) can lead to stomach bleeding and ulceration. NSAID 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 depression meds; ask your prescriber. The list goes on, so being proactive in checking interactions and discussing with your doctor or pharmacist is the best way to prevent harm.
Side Effects of Alcohol and Medication
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 other accidents leading to injury
- Liver or heart injury
- Breathing problems
- Drug overdose, death
Use Caution: Pills and Alcohol Use in Seniors
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.
However, the percent of seniors who drink alcohol is less when compared to their younger counterparts. Roughly 12% to 13% of older respondents were current drinkers in the NIH study, as compared to about 45% to 48% of those who were 40 to 64 years. Even though the percent of current drinkers in those 65 years and older is less, the possibility for interactions is high. 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? The biggest concerns are additive effects of alcohol and medications on the central nervous system, for example, increased drowsiness, dizziness, confusion and risk for falls and injury. The risk for greater side effects in the elderly due to enzyme interactions and increased or decreased levels of drug in the bloodstream, and altered drug effect, is a worry, too.
Alcohol and Medication Side Effects in Women
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 body water and greater body fat and 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.
Alcohol and blood pressure medication drug interactions may be taken for granted, too, leading to hypotension (low blood pressure) in some cases. Drinking on steroids (antiinflammatory medication like prednisone) can lead to stomach bleeding and ulceration. NSAID and alcohol use can also cause stomach problems.
Children and Alcohol
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 (e.g., methylphenidate or Ritalin) are combined.
Types of Drug Interactions With Alcohol
There are basically two types of drug interactions with alcohol. When a medication side effect like drowsiness is magnified by the use of alcohol it is called an “additive” effect. 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. These types of interactions are called “pharmacodynamic” interactions. They occur frequently when alcohol and pills that cause drowsiness are combined.
Metabolic, or “pharmacokinetic” interactions can also occur. 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).
How Is Alcohol Metabolized?
Alcohol is primarily metabolized by two enzymes in the body: 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.
With consumption of large amounts of alcohol, the CYP2E1 enzyme in the liver may be involved. A concern here is that drugs that are also metabolized by 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 chronic alcohol users, liver toxicity, and even liver failure, can occur, due to formation of toxic acetaminophen by-products.
Alcohol is known to strongly inhibit an enzyme in the liver known CYP2C9. When alcohol is consumed with other drugs that primarily use this enzyme for breakdown (metabolism) and excretion, blood levels of the other drug may theoretically increase, leading to increased side effects and toxicity. An example of this is with the drug interaction between warfarin and alcohol. Always check with your pharmacist to see if these types of enzyme interactions are of concern between your medications.
Do Herbal Medicines Interact With Alcohol?
The use complementary medicine and herbal medicine has grown tremendously over the last few decades. Ekor 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.
Top 20 Drug and Alcohol Interactions
- Valium (diazepam)
- Xanax (alprazolam)
- Adderall (metronidazole)
- Ibuprofen (Advil, Motrin)
- Zoloft (sertraline)
- Metronidazole (Flagyl)
- Azithromycin (Zithromax, ZPak)
- Benadryl (diphenhyramine)
- Lexapro (escitalopram)
- Tramadol (ConZip, Ultram)
- Tylenol (acetaminophen)
- Prozac (fluoxetine)
- Acetaminophen and Hydrocodone (Vicodin, Lorcet, Lortab, Norco, Xodol, Hycet)
- Hydrocodone (Hysingla ER, Zohydro ER) - 17
- Metformin (Glucophage)
- Doxycycline (Acticlate, Vibramycin)
- Ambien (zolpidem)
- Top 9 Ways to Prevent A Deadly Drug Interaction
- Herbal and Dietary Supplements Deserve Your Attention, Too
- Prescription Drug Addiction: Top 18 Facts for You & Your Family
- Anticholinergic Drugs to Avoid in the Elderly
- Antibiotics and Birth Control Pill Interactions: Fact or Fallacy?
The lists presented in this review do not include all the medicines that may interact harmfully with alcohol. To more closely examine specific interactions, visit the Drugs.com Interaction Checker and speak with your doctor or pharmacist.
Types of Drugs That Can Interact With Alcohol
- Acne Medicines and Alcohol
- ADHD Medications and Alcohol
- Allergies, Cough/Cold Medications and Alcohol
- Antibiotic Medications and Alcohol
- Antidepressant Medications and Alcohol
- Antipsychotic Medications and Alcohol
- Anxiety Medications and Alcohol
- Bipolar Medications and Alcohol
- Birth Control Medications and Alcohol
- Blood Thinners and Alcohol
- Caffeine, Energy Drinks and Alcohol
- Cholesterol Medications and Alcohol
- Diabetes Medications and Alcohol
- Enlarged Prostate (BPH) medications and Alcohol
- Erectile Dysfunction Medications and Alcohol
- Heart Medications and Alcohol
- Herbal Supplements and Alcohol
- Illicit Drugs and Alcohol
- Motion Sickness Medications and Alcohol
- Muscle Relaxants and Alcohol
- Pain / Fever Medications and Alcohol
- Seizure Medications and Alcohol
- Sleep (Insomnia) Medications and Alcohol
- Stomach / Heartburn Medications and Alcohol
- Weight Loss Drugs and Alcohol
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- The U.S. Centers for Disease Control and Prevention (CDC). Fact Sheets - Alcohol and Caffeine. June 9, 2017. Accessed October 31, 2017 at https://www.cdc.gov/alcohol/fact-sheets/caffeine-and-alcohol.htm
- 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, 2017 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 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3887317/
- Roemer A. Stockwell T. Alcohol Mixed With Energy Drinks and Risk of Injury: A Systematic Review. J Stud Alcohol Drugs. 2017 Mar;78(2):175-183. Accessed November 2, 2017 at http://www.jsad.com/doi/full/10.15288/jsad.2017.78.175
- Energy drinks: Do they really boost energy? Drugs.com. Accessed November 2, 2017 at /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 https://www.aap.org/en-us/about-the-aap/aap-press-room/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, 2017 at https://www.ncbi.nlm.nih.gov/pubmed/28324814
- Alcohol Facts & Statistics. National Institute on Alcohol and Abuse and Alcoholism (NIAAA). National Institutes of Health (NIH). Accessed Nov. 11, 2017 at https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/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, 2017 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC165791/