Norvir and Alcohol Consumption

Don C. Des Jarlais, PhD, Beth Israel Medical Center, New York City

The Problem. Norvir contains alcohol, which may provoke concern in patients with histories of alcohol dependence who are currently attempting to avoid any alcohol consumption. Norvir liquid has a higher alcohol content than Norvir capsules.

The actual amount of alcohol in the liquid form is rather modest. A 400 ml dose contains the amount of alcohol found in 1.5 ounces of beer (with a 5 percent alcohol content). This is equivalent to one-eighth of a 12-ounce can of beer. A 600 ml dose contains the amount of alcohol found in 2 ounces of beer-–one-sixth of a 12-ounce can. These amounts of alcohol are sufficiently small that one would not expect them to have any detectable psychoactive effect, even in persons who are quite sensitive to alcohol effects.

In addition to the very modest amount of alcohol in the Norvir liquid formulation, the noxious taste and possible nausea that accompany Norvir liquid are not likely to serve as "reinforcement" for taking the medication.

Despite the very modest amount of alcohol in the Norvir formulation and the non-reinforcing properties of the medication, there will be some HIV-seropositive patients with histories of alcoholism and who are presently "in recovery" who will be very concerned about consuming any alcohol.

Given the small amount involved, it may appear irrational for persons in recovery to be concerned about consuming alcohol while taking Norvir. Such concern, however, reflects current practice in many forms of addiction treatment and a long-standing controversy in the alcoholism field. Current practice in almost all alcoholism treatment in the US is to have the alcoholic abstain from all further alcohol consumption. Complete abstinence is the treatment goal even in relapse prevention treatment (discussed below), where "slips" are not seen as inevitably leading to a return to full alcoholic levels of drinking.

The controversy concerns whether it is possible for some alcoholics to become "controlled" drinkers, who consume limited amounts of alcohol without "losing control" and reverting to clearly self-destructive levels of alcohol use. Many people in treatment for alcohol abuse would like to be able to achieve controlled drinking, as this would (presumably) be a more enjoyable and less difficult lifestyle than total abstinence. It is even possible that many more problem drinkers would enter treatment for alcohol problems if controlled drinking were a treatment option.

There have been occasional studies showing evidence that some alcoholics are capable of becoming controlled drinkers. These studies have been criticized on methodological grounds (e.g., the subjects were not true alcoholics, the controlled drinking endpoint was not a true endpoint but a temporary stage on a path to uncontrolled drinking). The authors of such studies have also been criticized for allegedly endangering the lives of all alcoholics in recovery through offering a false hope that a return controlled drinking is possible.

Given the great variation in persons who are labeled as alcoholic, and analogies to other types of addiction, it would seem very likely that at least some alcoholics could practice at least some form of controlled drinking. (For example, some former cigarette addicts do smoke on an occasional basis without returning to addictive levels of use. These "controlled smokers" typically report rather intense pleasure from their occasional use of nicotine.)

If controlled drinking is theoretically possible for some alcoholics, however, there are at least two difficult pragmatic questions. First, there is at present no method of reliably determining which subset of alcoholics could practice controlled drinking. Trial-and-error experimentation, with those who cannot practice controlled drinking then returning to full alcoholic levels of drinking, would not be an ethically acceptable method. Second, there is also no method for determining what would be an appropriate level of alcohol consumption for such controlled drinking. Note that the level would probably have to be individually determined. Again, trial-and-error experimentation would not appear to be an ethically acceptable method. Given these pragmatic difficulties, the treatment goal of complete abstinence may be justified in terms of "First, do no harm," even for treatment professionals who suspect that controlled drinking may be possible for some alcoholics.

Concern about any alcohol consumption thus needs to be interpreted within the context of this background controversy about the possibility of controlled drinking. People in recovery who subscribe to the current orthodoxy that controlled drinking is not possible for alcoholics will be concerned that consuming any amount of alcohol is likely to lead to a full relapse to alcoholic levels of drinking.

It is also important to note that consuming alcohol without returning to full alcoholic levels of drinking is also not necessarily a good outcome for persons who subscribe to the current orthodox view. If it is possible to consume alcohol without reverting to high levels of drinking, then "controlled drinking" may be a possibility. The individual would then have to consider whether he or she wants to try controlled drinking, and what level of alcohol consumption might constitute controlled drinking for him or her. Additionally, if this primary tenet of recovery (the need to abstain completely from alcohol) is incorrect, what other components of recovery are also "wrong?"

Thus, the concern about consuming even modest amounts of alcohol needs to be addressed not only in terms of the possible physiological/psychoactive effect of the drug ethanol, but also in terms of the belief structure that is utilized to maintain the recovery process.

Strategies for addressing the concern about alcohol use. There are multiple strategies that can be used for patient concerns over consuming even very small amounts of alcohol:

1. Is the concern about consuming alcohol hiding other concerns about taking antiviral medications? There are a wide variety of reasons why patients may be concerned about taking anti-HIV medications. These can range from a simple change in medication schedule with the new Norvir formulation, concern about the difficulties of adherence, concern about maintaining the confidentiality of the HIV infection, to basic anxieties about being infected with HIV. If some other anxiety is the "basic" problem, then working only with the anxiety over alcohol consumption is not likely to be successful.

2. Is it possible to "cognitively redefine" the problem and apply principles of relapse prevention. For persons in recovery, the critical task is maintaining sobriety rather than avoiding the chemical ethanol. Thus, it is possible that a patient may come to see the small amount of alcohol in the medication as "taking medication" rather than "drinking alcohol" (either "controlled drinking" or "non-controlled drinking"). Taking the medication is done under very different conditions and for very different reasons than drinking alcohol (for both recovering alcohol addicts or for social drinkers). The important point is for the patient to differentiate between taking medication and drinking, and that taking medication has little or no implication of controlled versus non-controlled drinking or that the person will relapse back to alcoholic levels of drinking.

   Taking medication differs from drinking in many respects, including the expectations of the individual, the amount that is consumed, who is determining the amount to be consumed, the chemical formulation consumed, and the physical and social environments in which these events occur. Given these very large differences in "set and setting," both the response to the substance and the behavioral sequelae of using the substance can be completely different.

   It is worth noting that there are many medications that can produce at least some alcohol-like effects. Indeed, simple fatigue can sometimes produce alcohol-like effects. Thus, even experiencing some alcohol-like effects does not imply that the patient has lost sobriety and must return to alcoholic levels of consumption (or should try controlled drinking). It also may be useful to note, that with appropriate medical supervision, it is possible to prescribe narcotic analgesics to persons with histories of heroin addiction without the persons returning to heroin use (in either a controlled or uncontrolled fashion).

   Relapse prevention techniques can be used to help persons in recovery avoid situations in which return to addicted levels of drug use is likely. (See April 1998 JIAPAC.)

3. Spirituality and the assistance of a "higher power." Rationale arguments–whether made by the addict or by others – often are not sufficient to guide the behavior of the addict. Twelve-step programs involve admitting that one has lost control over substance use and asking for the assistance of a "higher power" in order to maintain sobriety. There are many forms of "alternative and/or complementary treatments" used by persons who may need to take medications that have alcohol in them (and who also need to adhere to complex medication schedules). Spiritual beliefs may also provide a source of strength.

Summary. The amount of ethanol in the liquid formulation of Norvir is quite modest and ordinarily should not lead to adverse psychoactive effects or adverse behavioral consequences. For some patients, however, this formulation may challenge important beliefs about their recovery from alcoholism. The importance of such beliefs to the health and welfare of these patients should not be underestimated. In these situations, it should be possible to use cognitive redefinition, relapse prevention and, possibly, spiritual beliefs, to assist them in working through these situations.

Posted 10/1/98

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