Polysubstance use disorder

From IDWiki

Background

Risk Factors1

  • Younger age
  • Lower education
  • Lower socioeconomic status
  • Childhood abuse
  • Male sex

Epidemiology

  • About 25% of people with one substance use disorder have co-occurring substance use disorders1.

Management

Screening

Treatment

  • The co-occurring disorders should ideally be treated concurrently, based on the severity of each one.

Benzodiazepine and opioid use disorders

  • Benzodiazepine use has a high risk of hepatitis c virus infection, HIV infection, and death.
  • Specifically with opioids, it increases the risk of respiratory depression, overdose, and death.
  • However, the risk of death from an untreated opioid use disorder is likely higher than if it is treated despite the concurrent use of benzodiazepines.
  • Despite this, opioids and benzodiazepines should not be coprescribed unless clearly documented as a taper.

Cocaine and alcohol use disorders

  • Old data suggest that as much as 60-80% of patients with cocaine use disorder have a concurrent alcohol use disorder.
  • Coingestion causes the formation of a cocaine metabolite cocaethylene, not otherwise present, which increases the effects (positive and negative) of the cocaine and prolongs its half-life.

Opioid and alcohol use disorders

  • Continue with standard treatments including motivational interviewing.
  • For medical management of the opioid use, Suboxone is likely safer in these patients than methadone.
  • For medical management of the alcohol use, naltrexone is contraindicated since it will precipitate withdrawal, but acamprosate and gabapentin can still be used.

Tobacco use disorder

  • Many patients who are being treated for other substance use disorders are interested in smoking cessation as well.
  • Patients should be screened and offered treatment for concurrent tobacco use disorder.

Alcohol and tobacco use disorders

  • This combination is the most common diagnosis among those with co-occurring substance use disorders.
  • Smoking is associated with increased alcohol consumption and severity of alcohol use disorder, as well as the usual ill effects of smoking and alcohol use.
  • Combination varenicline and naltrexone appears effective.
  • Psychosocial interventions including brief interventions and contingency management may be helpful.

Prognosis

  • More severe physical and mental health problems, including liver disease and HIV, compared to those with a single substance use disorder.
  • Concurrent use of sedatives, such as opioids with benzodiazepines or alcohol, is associated with higher rates of respiratory depression, overdose, and death.

References

  1. a b  Ish P. Bhalla, Elina A. Stefanovics, Robert A. Rosenheck. Clinical Epidemiology of Single Versus Multiple Substance Use Disorders. Medical Care. 2017;55:S24-S32. doi:10.1097/mlr.0000000000000731.