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The recovering person must be aware of the different types of and substances that may present a risk to their recovery. Recovering people should avoid any of these medications without the STOP CLASS A MEDICATIONS guidance of a qualified health care provider. The danger with using the medications listed in this guide is twofold. The first is that the Class A medications should be individual may be led back to the use of their of choice. The avoided completely. They are second is cross addiction, the use of a certain substance may develop known to produce addiction and into a new addiction. This guide does not include all but can be are the most dangerous of all. They should only be considered in used as a reference. It is necessary that the recovering person exceptional situations. Use of these become an informed consumer. Your recovery is your responsibility. medications should, of course, Informing all health care providers (physicians, pharmacists, dentists, include the supervision of a mental health providers) of one’s substance use history is absolutely physician and the inclusion of necessary. someone (a sponsor, family member) to ensure the is taken appropriately. This includes a long list of medications available that are safe for the recovering person. However, overuse of any medication can result in unwanted . These are known as Class C medications. CLASS B MEDICATIONS ! This guide also includes a section on incidental exposure, to caution the recovering person on substances that may not be as obvious as Class B medications are potentially dangerous when taken by a some of the products listed in this guide. recovering individual without the supervision of a health care Author: Janet Hicks, DPH. professional. Director of Professional Programs - CORNERSTONE of RECOVERY

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances. • Ale Because alcohol is a small molecule it interacts with many • Beer (including “nonalcoholic forms”) neurotransmitter systems in the brain: this makes the action • Brandy of alcohol in the brain very different from and much more • Liquor complex than large molecules such as , THC or • Wine and Wine Cooler which stimulate a specific neurotransmitter • Malt Beverage and interact with a specific system. Alcohol is known to interact with the following systems: GABA, Endorphins, Glutamate, , and . Be cautious of cough and cold preparations that may contain alcohol.

CBD • Avoid ALL products containing CBD

Cough Suppressants / • Any cough/cold medications containing codeine or o Phenergan with Codeine should not be used. These medication / (/codeine) combinations often contain other mood-altering /Expectorants o Phenergan VC with Codeine ingredients, such as chlorpheniramine and /Combination Products (promethazine/codeine/) . o Robitussin AC (codeine/) o Cheratussin DAC (codeine/guaifenesin/pseudoephedrine) o Notuss-DC (codeine/pseudoephedrine) • Hydrocodone o Tussionex PennKinetic ER (hydrocodone/chlorpheniramine) o Hydromet (hydrocodone/) Zutipro (hydrocodone/chlorpheniramine /pseudoephedrine)

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Ecstasy • MDMA (Methylenedioxymethamphetamine) Ecstasy is often combined with other drugs of abuse • MDA (Methylenedioxyamphetamine) increasing the risks of adverse effects. • MDE (Methylenediozyethylamphetamine) • MDMA increases dopamine, norepinephrine and serotonin.

Neuropathic Pain • Lyrica () These medications can produce and a “drunk or • Neurontin () high” feeling in certain individuals. The use of either medication can lead to withdrawal symptoms when discontinued.

Marijuana • Marinol () Marijuana can impair judgement and coordination. • Hash, THC Chronic use can lead to tolerance, dependence and withdrawal. These drugs cause initial drowsiness and sedation. Eating marijuana can lead to . Due to extended elimination time, marijuana can impair cognitive functioning for a day or more.

Inhalants • Nitrites (amyl, butyl) Nitrites can cause sedation and visual distortions. Solvents • Solvents (, , , , can cause disorientation and loss of muscle coordination. freon, coolants) Long term use can lead to depression, hallucinations, and • Glues damage to the brain, , lungs and kidneys.

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Hallucinogens • Lysergic Acid Diethylamide (LSD) effects include feelings of detachment from • (peyote, mescal) one’s surroundings, emotional swings and an altered sense • Belladonna (, ) of space and time. Physical effects jitteriness, racing or • (robo, Dex, DXM) slowed heartbeat, numbness, chills, , numbness and • (Special K, K) loss of coordination. PCP can cause , coma and • (mushrooms) . Belladonna alkaloids can stimulate the heart • (PCP, angel dust) and increase body temperature. When hallucinations • Dimethyltryptamine (DMT) occur, the user is very possibly in a life-threatening situation. “Flashbacks” of previous hallucinations can occur.

Stimulants • Even at therapeutic doses these medications increase heart • rate and . At high doses, one can expect • MDPV () stroke, seizures, and death. Repeated high • (/amphetamine) doses can lead to paranoia and hostility. Bizarre repetitive • Concerta (, long acting) movements can become extreme. Long term effects • Daytrana (methyphenidate patch) include bleeding in lungs, nasal ulcerations, stomach ulcers, • Dexedrine (dextroamphetamine) damage to the heart muscle, and impairment of memory • Focalin () and decision making. • Metadate (methylphenidate) • Methylin (methylpenidate) • Nuvigil (ammodafinil) • Provigil () • Quillivant (methylphenidate) • Ritalin (methylphenidate) • Vyvanse () • Mydayis (amphetamine salts)

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Anorexiants • These medications work in appetite reduction secondary to • Belviq () stimulating the central nervous system and have a high • Belviq is a serotonin . abuse potential. There is a caution regarding . This drug has the ability to produce hallucinations and euphoria, therefore may produce a psychic dependence. • Qsymia (phentermine combine with ) • Desoxyn (methamphetamine) • Regimex () • Suprenza (phentermine) • Tenuate (methylpropion)

Gastrointestinal (Anti-Diarrheal & • Donnatal (, atropine, ) , scopolaminegf • Lomotil, Lonox (atropine, )

• Motofen (atropine, )

• Paregoric ( tincture) • Viberzi () • Eluxadoline has action on the receptors (mu- agonist/antagonist and kappa receptor agonist. It can cause feelings of euphoria. • Librax (/clidinium) o Chlordiazepoxide is a

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Skeletal Muscle Relaxants • Soma () These medications can impair physical and mental abilities. • Skelaxin () They can produce euphoria. Tolerance and withdrawal • Robaxin () have been noted. • Zanaflex () • Flexeril () • Norflex (orphenidrine)

Sedatives • have some unexpected effects including anxiety, o Midrin, Migragesic, Nodolor nightmares, hostility and rage. Therapeutic doses can cause dizziness, drowsiness, impaired learning and . These medications are a combination of acetaminophen, Higher doses can lead to suppression of breathing and and isometheptane. The dichloralphenazone is a . heart failure. Tolerance and dependence happens over a short period of time. Sudden withdrawal can lead to • seizures. o Esgic, Bupap, Fioricet, Fiorinal, Phrenalin Forte, Margesic, Zebutal - These medications are combination products that contain o Seconal () o Phenobarbital o Nembutal () o Amytal ()

•

(continued…)

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Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Sedatives (continued) • Sedatives have some unexpected effects including anxiety, o Ambien () nightmares, hostility and rage. Therapeutic doses can o Belsomra () cause dizziness, drowsiness, impaired learning and amnesia. o Lunesta () Higher doses can lead to suppression of breathing and o () Sonata heart failure. Tolerance and dependence happens over a o Somnote ( hydrate) short period of time. Sudden withdrawal can lead to

These medications are not classified as benzodiazepines, seizures. but they act on a benzodiazepine receptor that leads to sleep.

• Central Nervous System o GHB (gamma-hydroxybutyrate)

Opiates • Opiates in high doses can lead to death due to depression o Buprenex (injection) of the respiratory system. In therapeutic doses, opiates can o Butrans (patch) cause slowed breathing, drowsiness, nausea, vomiting and o Suboxone . Tolerance and withdrawal are common. o Subutex o Zubsolv

• (Stadol)

• Codeine o #2, #3 or #4 tablets or Tylenol with Codeine Liquid (continued…)

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Opiates (continued) • Opiates in high doses can lead to death due to depression o Duragesic (patch) of the respiratory system. In therapeutic doses, opiates can o Sublimaze (injection) cause slowed breathing, drowsiness, nausea, vomiting and o Abstral () constipation. Tolerance and withdrawal are common. o Actiq (lozenge, transmucosal)

•

• Meperidine o Demerol

• o Dolophine o Methadose o Metadol

• o Dilaudid o Exalgo (extended release)

• Morphine o Avinza (extended release) o Embeda (morphine, ) o Kadian (extended release) o MS Contin (extended release) o Roxanol (morphine solution) o Astramorph, Duramorph, Infumorph (injection) (continued…)

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Opiates (continued) • Nubain () Opiates in high doses can lead to death due to depression of the respiratory system. In therapeutic doses, opiates can • Hydrocodone cause slowed breathing, drowsiness, nausea, vomiting and o Norco (hydrocodone/acetaminophen) constipation. Tolerance and withdrawal are common. o Vicodin (hydrocodone/acetaminophen) o Xodol (hydrocodone/acetaminophen) o Hysingla (extended release) o Zohydro (extended release)

• o Endocet, Endodan (oxycodone/acetaminophen, oxycodone/) o Oxycontin (extended release) o Oxy IR o Percocet, Percodan (oxycodone/acetaminophen, oxycodone/aspirin) o Roxicodone o Roxicet (oxycodone/acetaminophen solution) o Targiniq (oxycodone/ extended release) o Xartemis (oxycodone/acetaminophen extended release)

• o Opana

• Sufenta ()

(continued…)

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STOP

Use of Class A medications should be avoided completely, as they are well known to produce addiction and are the most dangerous of all. These medications should only be considered under exceptional circumstances.

Opiates (continued) • Opiates in high doses can lead to death due to depression o Talacen (pentazocine/acetaminophen) of the respiratory system. In therapeutic doses, opiates can o Talwin cause slowed breathing, drowsiness, nausea, vomiting and o Talwin NX (pentazocine/naloxone) constipation. Tolerance and withdrawal are common.

• o Nucynta o Nucynta ER

• o Ultram o Rybix o ConZip o Active-Tramadol, Enova RX (tramadol creams)

Decongestants • Benzedrex Inhaler (phenylhexedrine) This medication is a psychostimulant that works as a and appetite suppressant. It is euphoria producing and should be avoided.

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unless approved by addiction specialist/doctor !

Addiction Treatments

• Antabuse (disulfiram) - dangerous if taken with These medications typically require monitoring by a health alcohol care provider and should most often be used in the • Campral (acamprosate) conjunction with a recovery program. • Catapres () - decreases hyperactivity associated with withdrawal • Revia (naltrexone) • Vivitrol (naltrexone) • Zyban, Wellbutrin () - used to aid in cessation • Chantix () - used to aid in nicotine cessation

Anabolic Steroids • Androderm, Androgel, Axiron, Testim - topical This is the common name for synthetic preparations of the preparations male testosterone. Also known as . • Depo-Testosterone (testosterone cypionate) These are natural or synthetic steroid hormones that delayed release injection regulate the development and maintenance of male • Oxandrin (oxandrolone) oral - used for weight characteristics. As a Class B medication, uses include gain, and to reduce bone pain in certain inadequate testosterone production (men), endometriosis, patients with osteoporosis breast cancer, fibrocystic breast disease (women), weight • Androxy (fluoxymesterone) oral - used to treat gain and delayed puberty. Serious side effects are delayed puberty in male children, low testosterone levels and breast cancer associated with these products. Any use associated with • Testred, Android, Virilon, Methitest- oral performance enhancement or muscle growth would move - used to treat low these products to a Class A category. testosterone levels and breast cancer

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! unless approved by addiction specialist/doctor

Antihistamines- Sedating • Atarax ( hydrochloride) These medications should be used with caution as they can • () alter judgement and mood.

• Chlor-Trimeton, Coricidin (chlorpheniramine) • Periactin () • Tavist () • Vistaril (hydroxyzine pamoate)

Decongestants • Nasal Sprays containing These medications should be used with caution because o Afrin, Zicam Intense Sinus Relief, Vicks Sinex, they are stimulating and can precipitate relapse. Dristan, Nostrilla • Nasal Sprays containing phenylephrine o 4-Way, Neo-

• Oral Preparations (combination products) o Phenylephrine and phenylephrine containing combination medications (most also include sedating antihistamines, as well as dextromethorphan)

**Cautionary Ingredients Listed ▪ Advil and Congestion Relief – phenylephrine, chlorpheniramine ▪ Advil Sinus Congestion and Pain- phenylephrine ▪ Alka Seltzer Plus Multi-Symptom Combinations- phenylephrine, chlorpheniramine, , DM ▪ Allerest PE- phenylephrine, chlorpheniramine ▪ Benadryl Severe Allergy Plus Sinus Headache- phenylephrine, diphenhydramine

(continued…)

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! unless approved by addiction specialist/doctor

Decongestants **Cautionary Ingredients Listed (continued) These medications should be used with caution because (continued) ▪ Comtrex Cough and Cold- phenylephrine, they are stimulating and can precipitate relapse. DM ▪ Comtrex Cough and Cold Night- phenylephrine, chlorpheniramine, DM ▪ Contac Cold and Flu- phenylephrine ▪ Contac Cold and Flu Night- phenylephrine, chlorpheniramine ▪ Delsym Cough and Cold Day- phenylephrine, DM ▪ Delsym Cough and Cold Night- phenylephrine, diphenhydramine ▪ Dristan Cold- phenylephrine, chlorpheniramine ▪ Mucinex Cold/Sinus/Flu Combinations- phenylephrine, diphenhydramine, DM ▪ Robitussin Cold Multi-Symptom Combinations- phenylephrine, diphenhydramine, DM ▪ Sine Off- phenylephrine, chlorpheniramine ▪ Sudafed PE- phenylephrine ▪ Sudafed PE Combinations- phenylephrine, chlorpheniramine, DM ▪ Theraflu Combinations- phenylephrine, diphenhydramine, DM ▪ Tylenol Cold Multi-Symptom Combinations- phenylephrine, chlorpheniramine, DM

• Pseudoephedrine and pseudoephedrine containing combination medications (some include sedating antihistamines as well as dextromethorphan)

(continued…)

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! unless approved by addiction specialist/doctor

Decongestants **Cautionary Ingredients Listed These medications should be used with caution because (continued) ▪ Advil Cold and Sinus- pseudoephedrine they are stimulating and can precipitate relapse. ▪ Advil Allergy Sinus- pseudoephedrine, chlorpheniramine ▪ Alavert Allergy and Sinus- pseudoephedrine ▪ Aleve D Sinus and Cold- pseudoephedrine ▪ Allegra D Allergy and Congestion- pseudoephedrine ▪ Bromfed DM- pseudoephedrine, , DM ▪ Mucinex D- pseudoephedrine ▪ Nexafed Sinus- pseudoephedrine ▪ Pseudo-Gest, Sudafed, Silfedrine- pseudoephedrine ▪ Semprex-D- pseudoephedrine,

• Epinephrine

o Asthmanefrim o Primatene o Bronkaid

Antitussives/ Expectorants **Cautionary Ingredients Listed Dextromethorphan (DM) is the antitussive ingredient in these • Coricidin HBP Multi-Symptom Combinations- medications. DM suppresses the cough center in the brain. dextromethorphan, chlorpheniramine, It also has sedative, and properties. doxylamine At high doses it can mimic the effects of PCP and • Delsym Cough- dextromethorphan Ketamine. • Mucinex DM- dextromethorphan • Phenergan DM- dextromethorphan, These products may contain sedating . promethazine • Robitussin DM – dextromethorphan Dextromethorphan combined with chlorpheniramine can • Vicks Cough DayQuil- dextromethorphan produce a serotonin syndrome like toxicity. • Vicks NyQuil- dextromethorphan, doxylamine

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unless approved by addiction specialist/doctor !

Corticosteroids • These medications are used for a variety of conditions. They • have value due to their anti-inflammatory, • immunosuppressive, anti-proliferative and vasoconstrictive • effects. These are also the reasons they must be taken as • directed. Their use can cause and nervousness, in • Fludrocortisone addition to bone loss and cataracts.

Asthma/ COPD/ Pulmonary- Inhaled • Advair- , These medications may suppress the immune system. • Azmacort- Advair and Serevent contain salmeterol that may produce • Flovent- fluticasone central nervous system stimulation. • Pulmicort- • Serevent- salmeterol • QVAR- beclomethasone

Gastrointestinal • Constipation These medications should be used in caution as frequent o Dulcolax- bisacodyl use can cause electrolyte imbalance, dehydration, irregular o Senokot-S- sennosides heartbeat, and decreased immune response. o Senokot- sennosides • Nausea/Vomiting o Compazine () and Phenergan (promethazine) are . This class of medications can inhibit cognitive abilities and cause sedation. In high doses, a dissociative state may occur. o Reglan () may cause abnormal muscle movements that may not stop when this medication is discontinued. o Zofran () may produce serotonin syndrome when combined with certain medications. • o Imodium ()- a partial opioid agonist

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! unless approved by addiction specialist/doctor

Sleep Aids **Cautionary Ingredients Listed These medications contain sedating antihistamines and are • Advil PM- diphenhydramine considered mood altering. • Aleve PM- diphenhydramine • Excedrin PM- diphenhydramine • Nytol- diphenhydramine • Sominex- diphenhydramine • Tylenol PM- diphenhydramine • Unisom Sleeptabs- doxyamine • Vicks ZzzQuil- diphenhydramine • / • Bonine- • Dramamine- These medications can impair cognitive functioning • Transderm Scop- scopolamine producing dizziness, drowsiness and blurred vision.

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for recovering individuals  These medications are generally safe; however, overuse of any medication can result in unwanted side effects.

Alzheimer’s Disease • Aricept () and Memory Loss • Namenda () • Exelon (rivastigmine) • Razadyne ()

Migraines • Triptans o Amerge (naratriptan) o Maxalt (rizatriptan) o Axert (almotriptan) o Relpax (eletriptan) o Zomig (zolmitriptan) o Frova (frovatriptan) o Imitrex (sumatriptan)

• CGRP Receptor Blocker o Aimovig (erenuman)

• Beta Blockers o , , , ,

• Miscellaneous o Botox

Anticonvulsants/Mood Stabilizers • Topomax, Trokendi (topiramate) • Zonegran () • Depakene () • Keppra ()

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for recovering individuals  Anticonvulsants/ • Topomax, Trokendi (topiramate) Mood Stabilizers • Zonegran (zonisamide) • Depakene (valproate) • Keppra (levetiracetam)

Antihistamines • Alavert, Claritin () • Allegra () • Clarinex () • Zyrtec () • Xyzal ()

Anti-Parkinsonians • Mirapex () • Requip () • Sinemet (/levodopa)

Antitussives/ Expectorants • Mucinex (guaifenesin) • Tessalon Perles (benzonatate)

Asthma/COPD/ Pulmonary • Oral o Singulair () o • Inhalers o Breo (fluticasone/) o Advair (fluticasone/salmeterol) o Combivent (albuterol/ipratropium) o Proair, Ventolin, Proventil (albuterol) o Serevent (salmeterol) o Spiriva (tiotropium) o Xopenex (levalbuterol)

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for recovering individuals

/Antivirals • o , ampicillin, • Cephlasporins o Cefaclor, cefuroxime, cefprozil, cefadroxil, cephalexin, cefdinir, cefpodoxime • o Doxycycline, minocycline, • Lincosamides o , lincomycin • Macrolides o , , • Sulfonamides o / • Quinolones o , , , • o Fluconazole, ,

Antihypertensives

• ACE Inhibitors o Ramipril, benazepril, fosinopril, lisinopril, enalapril • ARB (angiotensin receptor blockers) o Valsartan, losartan, irbesartan, olmesartan • Beta Blockers o Propranolol, , metoprolol, atenolol, • Blocker o , , ,

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for recovering individuals  Anticoagulents/ • Warfarin, clopidogrel, rivaroxaban, apixaban, Antiplatelets heparin

Diuretics • , , torsemide, , hydrochlorothiazide

Cholesterol Lowering • Rosuvastatin, , ezetimibe, atorvastatin, gemfibrozil, pravastatin, fenofibrate

Diabetes • Pioglitazone, glimiperide, glyburide, metformin, , insulin

Erectile Dysfunction • , ,

Gastrointestinal • , , metoclopramide, pantoprazole, , esomeprazole, lansoprazole, , dicyclomine

Genitourinary • , , ,

Gout Allopurinol, colchicine

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for recovering individuals  Nasal Sprays • Ipratropium, cromolyn, , fluticasone

Non-Steroidal Anti-Inflammatory • , , , Medications indomethacin, , meloxicam, , , nabumetone COX-2 Inhibitors •

Osteoporosis • Risedronate, ibandronate, raloxifene, alendronate

Psychotropics/ • (Abilify), (Buspar), (Celexa), (Clozaril), (Cymbalta), divalproex (Depakote), (Vistaril), lithium, (Geodon), (Haldol), (Lexapro), (Luvox), (Pamelor), (Paxil), (Prozac), (Remeron), (Risperdal), , (Effexor), (Elavil), (Strattera), bupropion (Wellbutrin), (Zoloft), (Zyprexa), (Trintellix)

Thyroid • Thyroid, , thyroxine

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Since new markers for alcohol use have been developed, it is important that individuals in monitoring programs try to avoid incidental exposure. The sensitivity of the various types of drug testing make it imperative to use caution when using products that may contain alcohol. Alcohol does not need to be ingested to produce a positive test, it may come from topical application and inhalation of vapors.

Possible Sources of Incidental Exposure

Foods Foods can contain varying amounts of alcohol. Avoid foods cooked with or containing alcoholic beverages. Avoid foods containing high amounts of vanilla extract, wine vinegar, soy sauces, and other ingredients with alcohol content on their labels.

Hygiene Products Many hygiene related products contain alcohol and should be avoided. Examples include mouthwashes (Listerine may contain up to 25%, Cepacol 15%) and hand sanitizers (Purrell may contain up to 63%, Lysol 63%).

Other sources of alcohol exposure “Alcohol free” beer and wine often contain alcohol in varying low amounts. Avoid deodorant sprays, hairsprays, cosmetics, and insecticides (insect repellants). These products may contain ethanol vapor and can be inhaled or absorbed through the skin.

OTC (Over the Counter) There are many OTC medications that contain alcohol, including cough/cold preparations and tonics/tinctures. Medications Below is a limited list of examples. • Cough/Cold o Diphenhydramine Elixir 5%, Vicks Nyquil 10%, Vicks Formula 44D 5%, Cheracol-D 5% • Vitamin Tonics o Gevrabon 20%, Geritol 10%, SSS Tonic 12%, Niferex/Nu-Iron 10%

Prescription Medications Many liquid oral preparations contain alcohol, as well as some asthma inhalers. Always check with your health care provider.

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