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Water resources in many arid to semi-arid regions are stressed by population growth and drought. Growing populations and climatic changes are influencing contaminant and water chemistry dynamics in urban inland waters, where flows can be dominated by, or even dependent on, wastewater effluent discharge. In these watersheds, interacting stressors such as dissolved oxygen and environmental contaminants (e.g., pharmaceuticals) have the potential to affect fish physiology and populations. Recent field observations from our group identified the calcium channel blocker (CCB) diltiazem in fish plasma exceeding human therapeutic doses (e.g., C-min) in aquatic systems impaired because of nonattainment of dissolved oxygen water quality standards. Therefore our study objectives examined: 1) standard acute and chronic effects of dissolved oxygen and diltiazem to fish, 2) influences of dissolved oxygen at criteria levels deemed protective of aquatic life on diltiazem toxicity to fish, and 3) whether sublethal effects occur at diltiazem water concentrations predicted to cause a human therapeutic level (therapeutic hazard value [THV]) in fish plasma. Dissolved oxygenxdiltiazem co-exposures significantly decreased survival at typical stream, lake, and reservoir water quality standards of 5.0 and 3.0mg dissolved oxygen/L. Dissolved oxygen and diltiazem growth effects were observed at 2 times and 10 times lower than median lethal concentration (LC50) values (1.7 and 28.2mg/L, respectively). Larval fathead minnow (Pimephales promelas) swimming behavior following low dissolved oxygen and diltiazem exposure generally decreased and was significantly reduced in light-to-dark bursting distance traveled, number of movements, and duration at concentrations as low as the THV. Individual and population level consequences of such responses are not yet understood, particularly in older organisms or other species; however, these findings suggest that assessments with pharmaceuticals and other cardioactive contaminants may underestimate adverse outcomes in fish across dissolved oxygen levels considered protective of aquatic life. Environ Toxicol Chem 2018;37:2835-2850. (c) 2018 SETAC