Polysubstance use disorder: Difference between revisions
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+ | ==Background== |
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+ | *Co-occurring [[Substance use disorder|substance use disorders]] are common, involving both legal and illegal substances. |
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+ | *[[Tobacco use disorder]] and [[alcohol use disorder]] are the most common co-occurring substance use disorders, followed by [[opioid use disorder]], [[cocaine use disorder]], and [[cannabid use disorder]]. |
| − | === |
+ | ===Risk Factors[[CiteRef::bhalla2017cl]]=== |
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+ | *Younger age |
| − | * |
+ | *Lower education |
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+ | *Lower socioeconomic status |
| − | * |
+ | *Childhood abuse |
| − | * |
+ | *Male sex |
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| + | === Epidemiology === |
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| + | |||
| + | * About 25% of people with one substance use disorder have co-occurring substance use disorders[[CiteRef::bhalla2017cl]]. |
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| + | |||
| + | == Management == |
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| + | |||
| + | === Screening === |
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| + | |||
| + | * [[ASSIST]], [[TAPS]], and [[AUDIT-C]] can all be used |
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| + | === Treatment === |
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| + | |||
| + | * The co-occurring disorders should ideally be treated concurrently, based on the severity of each one. |
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| + | |||
| + | ==== Benzodiazepine and opioid use disorders ==== |
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| + | |||
| + | * Benzodiazepine use has a high risk of [[hepatitis c virus]] infection, [[HIV]] infection, and death. |
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| + | * Specifically with opioids, it increases the risk of respiratory depression, overdose, and death. |
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| + | * 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. |
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| + | * Despite this, opioids and benzodiazepines should not be coprescribed unless clearly documented as a taper. |
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| + | |||
| + | ==== Cocaine and alcohol use disorders ==== |
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| + | |||
| + | * Old data suggest that as much as 60-80% of patients with [[cocaine use disorder]] have a concurrent [[alcohol use disorder]]. |
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| + | * 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. |
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| + | |||
| + | ==== Opioid and alcohol use disorders ==== |
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| + | |||
| + | * Continue with standard treatments including motivational interviewing. |
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| + | * For medical management of the opioid use, [[Suboxone]] is likely safer in these patients than [[methadone]]. |
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| + | * For medical management of the alcohol use, [[naltrexone]] is contraindicated since it will precipitate withdrawal, but [[acamprosate]] and [[gabapentin]] can still be used. |
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| + | ** However, [[gabapentin]] should be used with care, since concomitant [[opioid]] and [[gabapentin]] use may increase fatal overdose compared to those without [[gabapentin]] use. |
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| + | |||
| + | ==== Tobacco use disorder ==== |
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| + | |||
| + | * Many patients who are being treated for other substance use disorders are interested in smoking cessation as well. |
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| + | * Patients should be screened and offered treatment for concurrent [[tobacco use disorder]]. |
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| + | |||
| + | ==== Alcohol and tobacco use disorders ==== |
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| + | |||
| + | * This combination is the most common diagnosis among those with co-occurring substance use disorders. |
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| + | * 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. |
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| + | * Combination [[varenicline]] and [[naltrexone]] appears effective. |
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| + | * Psychosocial interventions including brief interventions and contingency management may be helpful. |
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| + | |||
| + | == Prognosis == |
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| + | |||
| + | * More severe physical and mental health problems, including liver disease and HIV, compared to those with a single [[substance use disorder]]. |
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| + | * Concurrent use of sedatives, such as [[opioids]] with [[benzodiazepines]] or alcohol, is associated with higher rates of respiratory depression, overdose, and death. |
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Revision as of 10:28, 9 July 2020
Background
- Co-occurring substance use disorders are common, involving both legal and illegal substances.
- Tobacco use disorder and alcohol use disorder are the most common co-occurring substance use disorders, followed by opioid use disorder, cocaine use disorder, and cannabid use disorder.
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.
- However, gabapentin should be used with care, since concomitant opioid and gabapentin use may increase fatal overdose compared to those without gabapentin use.
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
- 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.
