Psychotropic Drug Interactions with Illegal Drugs/Non‐Drugs Antidepressants Amitriptyline/TCAs Alcohol ↑ sedation, ↓ seizure threshold Smoking ↓[TCAs] Caffeine Grapefruit juice Ok ↑[Clomipramine]? Mianserin Trazodone MAOIs ↑ sedation ↑ sedation ↑ sedation, HT crisis hypotension ↑ Caffeine effect (CNS stimulant) Moclobemide Citalopram/ escitalopram Fluoxetine Sertraline Fluvoxamine ↑ Sedation, HT crisis? ok ? ↑ Caffeine effect* SS? ok ok ↑ sedation ↓[Fluvoxamine] SS? ↑[Sertraline] ↑ [Fluvoxamine] Paroxetine ↑ sedation Duloxetine Mirtazapine Reboxetine Venlafaxine Agomelatine Tryptophan Liver injury? ↑ sedation ok ok Not advisable ↓[Duloxetine] ↓[Mirtazapine]? ↓[Agomelatine] insignificant SS? SS? SS? ↑Caffeine SS ok Smoking ok ok ↓[Benperidol]* ↓[Chlorpromazine] ↓[Clozapine] ↓[Fluphenazine] LSD ↓ LSD response ↑ flashback, seizures ↑flashback Cannabis Delirium, tachycardia ↑HR Altered mental state Ecstasy Arrhythmia ‐ avoid Amfetamine Arrhythmia ‐ avoid Heroin Avoid ↑ sedation CNS depression Cocaine Arrhythmia ‐ avoid St John’s Wort / others ↓[TCA] Tyramine in foods Ascorbic acid HT crisis, SS HT crisis, SS avoid Avoid for 14/7 Minor physiological effects HT crisis? HT crisis HT crisis, SS ↓ Ecstasy effect HT crisis, SS SS Avoid for 14/7 HT crisis? SS Avoid 14/7 Ginseng? Avoid 14/7 SS HT crisis mania ↓ Ecstasy effect? ↑[Ecstasy] SS,↑Amfetamine effect SS SS ↑[Cocaine], SS SS SS Hypomania, SS SS ↓ Ecstasy effect? ↑[Ecstasy]? ↑[Ecstasy] SS SS Sedation? SS avoid SS Ecstasy Antagonistic effect Antagonistic effect Amfetamine Antagonistic effect Antagonistic effect Heroin ↑sedation* ↑sedation* ↑ sedation CNS depression ↑ sedation ↓euphoria* Cocaine Dystonia? ↑[Cocaine] syncope Tyramine in foods ↓ euphoria, ↑[Haloperidol]* Cardiac toxicity?* St John’s Wort / others ↓[Aripiprazole]? EPO – seizures* ↓[Clozapine] EPO – seizures Betel nut* Ginseng Ginkgo ok* Ascorbic acid Rash? ↓ [Fluphenazine] ↑flashback Caffeine ↑[Clozapine] Grapefruit juice ok LSD Cannabis ↑ sedation* ↑ sedation* ↓[Chlorpromazine] ↓[Clozapine] ↓[Fluphenazine]* Antipsychotics Amisulpride Aripiprazole Asenapine Benperidol Chlorpromazine Clozapine Fluphenazine Alcohol CNS depression CNS depression CNS depression CNS depression CNS depression, liver tox,EPSE CNS depression CNS depression, EPSE Haloperidol CNS depression, EPSE ↓[Haloperidol] ok* ok ↓ Amfetamine effect, EPSE? ↑ sedation CNS, depression Prochlorperazine Trifluoperazine and other phenothiazines Olanzapine CNS depression, EPSE ↓[Perphenazine],↓[Fluphenazine] Antagonistic effect Antagonistic effect ↑ sedation CNS depression CNS depression, ↑HR, postural hypotension ↑ sedation Postural hypotension CNS depression ↓[Olanzapine] ↑ sedation, ↓[Olanzapine] ↑ sedation ↑[Quetiapine] ↑sedation ↑ sedation ↓[Quetiapine] No reports? ↓[Paliperidone] ↓ euphoria* ↓euphoria* Dystonia? ↓ craving CNS depression ↓ euphoria* ↓ euphoria* ↓euphoria* ↑ sedation CNS depression ↑ sedation Substance misuse Methadone Alcohol CNS depression Smoking ↓ [Methadone] Caffeine Grapefruit juice ↑ [Methadone] LSD Ecstasy Amfetamine Heroin ↑ sedation CNS depression Tyramine in foods Ascorbic acid ok ↑[Ecstasy] Seizures? ↑ sedation CNS depression Disulfiram ↑ seizures Liver toxicity? ok ↑ sedation* CNS depression ↑ sedation ↑ anxiety ↓ BP arrhythmia collapse Cocaine ↓[Methadone] ↑ QTc Seizures? ↓ [Buprenorphine] St John’s Wort / others ↓ [Methadone] Bupropion Naltrexone Nalmefene Lofexidine Buprenorphine Chlordiazepoxide Cannabis ↓[Methadone]? ↑ sedation ↑cannabis effects? Hypomania, acute confusion ↑[Cocaine] paranoia Antagonistic effect ↑ [Caffeine] Acamprosate Anxiolytics/ hypnotics Benzodiazepines Alcohol Smoking Caffeine Grapefruit juice LSD Cannabis Ecstasy Amfetamine Heroin Cocaine St John’s Wort / others Tyramine in foods Ascorbic acid CNS depression ↓ anxiolytic effect ↓ [Benzodiazepines] ↓ z‐drug effect? ↓[Melatonin] ↓ Benzodiazepine effect ↓ sedation, ↑ anxiety ↑ [Benzodiazepines] ↑ [Zopiclone/Zolpidem]* ↑ [Buspirone] ↑ sedation CNS depression ↑ sedation Ok* ↑ sedation CNS depression ↑ sedation ↓ [Zopiclone/Zolpidem] SS? ↑ sedation ↑ sedation Smoking ↑[Lithium]* Caffeine ↓[Lithium] Grapefruit juice LSD Cannabis ↑ sedation, ↑ [Lithium] Amfetamine ↓Amfetamine effect? Heroin Cocaine ↓ cocaine effect* Tyramine in foods Ascorbic acid St John’s Wort / others Mania with SJW. Lithium toxicity with herbal diuretics ↑ cardiac side effects ↓[Carbamazepine]? Quetiapine Risperidone Paliperidone Flupentixol Zuclopenthixol Sulpiride Zopiclone/ zolpidem ↑ sedation Chloral H/sedating antihistamines Pregabalin Melatonin Buspirone CNS depression ↑ sedation Reduced melatonin effect ↑ sedation Mood stabilisers Lithium Alcohol ↑ [Li]? (dehydration) ↓[lam] ↑ sedation ↑ sedation ↓ effect ↑[Melatonin] Lamotrigine/ Valproate Carbamazepine Ecstasy ↑ [Lithium]? (dehydration) ↓Ecstasy effect? ↓[nicotine] ↓[Carbamazepine]? ? ↑ [Carbamazepine] BP: Blood pressure // BZ: Benzodiazepines // CNS: Central nervous system // EPO: Evening primrose oil // HR: Heart rate // HT: Hypertension // […]: Blood level of the drug in brackets is affected as arrow indicates. //SS: serotonin syndrome – Please note list is not exhaustive. Always check with your ward pharmacist/medicines information department for advice. * Information from previous version – no reports in reference sources No reports found regarding this combination Combination studied no issues reported Combination studied caution advised Combination studied serious risk reported. “Legal Highs”.
So called “legal highs” are being developed all the time and too many are available to be included on this poster. Some guidance can be obtained by comparing how they act to one of the illegal substances listed. However, if more accurate information is needed, a formal Medicines Information query should be raised.
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February 2014 Psychotropic Dug Directory, Bazire 2014 The Maudsley Prescribing Guidelines in Psychiatry, 2011 Stockley’s Drug Interactions, online edition available from www.medicinescomplete.com Review February 2016