There is a hospital in Brooklyn, New York City, where history was made in taking better care of addicted patients. This is Maimonides Medical Center. Their intensive care unit (ICU) used to have a largely geriatric patient population, but in just two years, they were overtaken by younger patients in withdrawal from alcohol and polysubstance abuse.
The majority of the withdrawal patients came from the emergency department. Most of the time, they were intubated (tube inserted into a body part) because of oversedation, resulting in a younger population with tracheostomies (cuts in the windpipe to aid in breathing).
Most patients were admitted with multiple comorbidities (simultaneous presence of two or more chronic conditions in one patient), such as pneumonia and gastrointestinal bleeding. As doctors weren’t able to determine proper patient history, these patients began withdrawing 72 hours into their ICU stay. They were agitated, combative, kept falling over or climbing over side rails, and took most of the staff’s time. Nurses also noted that medications were very sedating and sometimes kept patients from timely extubation (tube removal).
The staff needed clear guidelines to clinically manage these patients. Specifically, they needed a more objective method of measuring patients’ agitation and an improved way to medicate them. So nurses Laurie Wilson and Christina Ycaza-Gutierrez led a team to develop a system that would alleviate staff anxiety when caring for these patients, decrease tracheostomies and falls, reduce ventilator days, and decrease ICU stay.
They created the evidence-based, nurse-driven Protocol for the Management of Alcohol and Polysubstance Abuse. It used the Richmond agitation sedation scale (RAAS) to earlier recognize and reduce the severity of withdrawal symptoms. This protocol is just one method among many that has proven effective in the fight against addiction.
What is polysubstance abuse?
This means using to excess more than one drug at the same time or alternating between two or more drugs to counteract the side effects of the other. This practice does not only amplify the pleasurable effects of drugs of abuse, but also the negative ones, increasing the chances of becoming addicted.
Polysubstance abuse also includes using prescription medications non-medically. It is extremely dangerous and more difficult to treat than an addiction to one drug. Consequences can be unpredictable.
Polysubstance dependence means a user is more dependent on the act of using itself than to a particular substance. Users may have a preferred substance that they abuse with other drugs. It can be alcohol, street drugs, opioids, prescription medication, or a combination of these. Multiple addiction means the user is addicted to more than one of these substances.
The most common preferred substance
Although any combination of drugs can be used in polysubstance abuse, studies have shown that alcohol is the one most commonly used with another substance. So it can be mixed with any of the following:
- Adderall (prescribed for ADHD)
- Zolpidem (a sedative/ hypnotic; brand: Ambien)
- Alprazolam (an anti-anxiety benzodiazepine; brand: Xanax)
- Lorazepam (a benzodiazepine for anxiety disorders, insomnia, seizures, alcohol withdrawal; brand: Ativan)
- Oxycodone (synthetic analgesic drug similar to morphine; brand: OxyContin)
- Tramadol (painkiller)
Polydrug abuse and mental health issues
When patients have both a substance use disorder and a mental disorder, they are more likely to engage in polysubstance abuse. This often makes the symptoms of the mental health disorder worse. The mental health issue can also exacerbate the substance abuse.
Patients with multiple addictions may also have simultaneous mental health problems disrupting their personal lives. Such cases require treatment with a multi-level approach and a customized treatment plan that targets the entire spectrum of dependency. Mental health treatment through a rehab program that treats co-occurring issues, as well as recovery services for substance abuse, is appropriate.
Diagnosis and changes in classification
In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-4 (1994 and 2000), polysubstance dependence was listed as an individual disorder. In order for people to be diagnosed with polysubstance dependence disorder, they had to be dependent on three or more addictive substances (stimulants, hallucinogens, depressants)—without preference for, or dependence on, a specific substance—for at least one year.
In the fifth and current edition, DSM-5 (2013), polysubstance dependence was removed as an individual diagnosis and placed under the new category of ‘substance use disorder’. This category now includes dependence, abuse, and addiction. The drugs must now be specified .
Polysubstance abuse in young adults
Adolescents are the most likely group to mix different types of drugs. A NIDA study found that 7 out of 10 teenage drug users combined prescription painkillers with drugs and alcohol. These teens were also more likely to abuse marijuana and get drunk. Combining drugs puts teens at a higher risk of addiction and overdose.
Polysubstance abuse in older adults
According to the New York State Office of Alcoholism and Substance Abuse Services, 10% of the USA’s population abuses alcohol, and about 17% of adults aged 65 and over suffer from alcohol abuse disorders.
Older adults absorb alcohol at a higher rate, getting intoxicated faster. Alcohol dependence, complicated by over-the-counter and prescription drug abuse, is common among baby-boomers. Some combine substances unintentionally, but this can be as lethal. According to Dr. Harry Haroutunian, author of Not As Prescribed, the number of addicted older adults in the US is expected to double to six million by 2020.
Reasons why people become polysubstance-dependent
- They have built up tolerance to more than one drug because they’ve used these continuously or to excess. When users’ minds and bodies get used to these drugs, they need them to function normally. So they use more to maintain the high they got in the beginning.
- Taking more drugs can amplify the effects of each. Many prescription drugs are enhanced when taken with alcohol. For example, since they are both central nervous system depressants, alcohol can enhance the calming effects of Valium.
- They take additional drugs to counteract side effects of the one(s) they’re already taking. For example, to calm themselves after a cocaine or amphetamine high, they take anxiety medication or sedatives.
- Polysubstance abuse creates new, more euphoric highs. But when use is stopped suddenly, drug cravings skyrocket and withdrawal symptoms take over.
- Common among athletes is the abuse of anabolic steroids. Not so common is their combination with cocaine for ergogenic effects: to enhance physical performance and stamina, or for faster recovery from injury.
- To experience new different sensations from multiple drugs.
- Users may be on multiple prescriptions from different doctors, not realizing that some medications interact negatively with each other. This is why patients should always inform their doctors of all medications they’re taking.
- To be able to drink alcohol more than normal.
- To avoid withdrawal symptoms.
Who is most at risk for polysubstance abuse or dependence?
- Those who are alcohol-addicted or alcohol-dependent
- Those on anxiety, depression, or pain medications, and who drink occasionally
- People who are active in club or rave scenes frequently take multiple drugs or experiment with various substances while drinking
- People with ADHD or similar disorders are more prone to impulsive behaviour and have a higher risk of polysubstance abuse
The dangers of polysubstance abuse
In general, when one prescribed drug is taken by itself according to the directions of a doctor/therapist, it is relatively safe, with a low risk of harmful side effects. But the dangers of one medication increase significantly when taken simultaneously with other drugs. Abusing multiple drugs increases the risk of dangerous drug interactions, overdose, addiction, accidents, fatalities, and other dangers.
Many users assume that prescription medication is not as dangerous as illicit drugs, so they combine these with different substances. When multiple drugs are combined, a phenomenon known as ‘boosting’ – a user’s heightened response to drugs – can occur.
Combined drug intoxication is a frequent cause of emergency room visits. Consequences vary with each combination.
Some negative effects are:
- In severe cases, the biggest risks are brain damage, coma, and death.
- Increased severity of side effects associated with the abused drug. These include nausea, vomiting, stomach bleeding, seizures, heatstroke, physiological pain, and balance issues.
- The combination of alcohol and prescription drugs can result in alcohol poisoning, blackouts, respiratory depression, and death.
- Decrease/increase in heart rate, respiration rate, and blood pressure.
- Damage to internal organs leading to liver, kidney, lung, and heart problems.
- Chronic diseases connected to the cardiovascular, gastrointestinal, and nervous systems.
- Drug interactions can reduce metabolism, increasing the levels of the abused substances in the blood.
- Increased levels of toxicity from the breakdown of multiple substances.
- Users who have experienced the combined effects of multiple substances may not be satisfied with using a single drug. This leads to an increased risk of overdose.
- Since certain substances mask the effects of others, users may inadvertently take higher doses than they normally would because they don’t feel the full effects of one substance.
- Exacerbation of present mental health issues—or the development of new ones.
- The combination of alcohol and painkillers can cut oxygen supply, leading to respiratory failure.
- Mixing stimulants, such as ecstasy (methylenedioxymethamphetamine) and cocaine, can increase euphoria, but may also cause a heart attack.
- Polydrug use severely depletes the brain’s feel-good and calming chemicals, which can lead to behavioural issues, depression and anxiety.
- Nicotine can boost adrenaline in the body. This not only increases blood pressure, pulse and heart rates, but also levels of the neurotransmitter dopamine in the reward centre of the brain. Over time, this can lead to addiction.
- Since drugs affect the brain, associated mood changes can cause suicidal thoughts and tendencies, especially after ingestion of pharmaceutical products combined with other drugs or alcohol.
- In the case of an alcohol and cocaine combination, when the liver metabolizes these two substances simultaneously, it will produce cocaethylene, which enhances euphoric effects. But it will also increase blood pressure and promote violent and aggressive thoughts, and affect judgement. When cocaethylene reaches toxic levels, it can lead to seizures, liver damage, impairment to the immune system, and sudden death.
- Opiates, alcohol, and benzodiazepines are all central nervous system depressants. Combining them can quickly result in respiratory problems that can lead to overdose. Benzodiazepines are not metabolized as quickly by older drug users. This increases the risk of respiratory complications.
- At high doses, the cough suppressant dextromethorphan (DXM) can cause hallucinations. Promethazine-codeine cough syrup has an antihistamine that induces sedation. These medications are often abused in combination with alcohol or marijuana.
Not all modalities work for everyone. Experts agree that the most effective treatment program is a customized one that will address all of a patient’s needs, not just those related to their substance abuse. This involves identifying the causes of the substance abuse, and dealing with them appropriately. As treatment progresses, changes may need to be made.
For recovery to be effective, addiction specialists recommend a combination of the following: detoxification, medication, complementary therapy, and group support.
Why a residential program is necessary for detoxification
Experts recommend inpatient medical detox and a longer-stay residential treatment program at a rehab facility because withdrawal symptoms from polysubstance abuse are worse than those from one drug only. Staff will address each drug’s side effects, beginning with the most severe.
With medical detox, patients are monitored 24/7 by medical personnel. Doctors administer medications for withdrawal symptoms, such as anti-nausea medications for vomiting and antidepressants for mood swings. Medical detox (as opposed to at-home withdrawal) decreases the odds of relapse and provides a better chance of successful withdrawal from all substances of abuse.
Medication-assisted treatment (MAT)
For combinations of Vicodin and cocaine, for example—or alcohol and painkillers— medical staff may administer an opioid replacement medication, such as methadone or buprenorphine, to lessen the severity of opioid withdrawal. Since cocaine withdrawal symptoms aren’t as intense, they may simply be monitored and medicated as needed.
Reducing dosages too quickly or quitting cold-turkey can result in severe and even life- threatening withdrawal symptoms. Without the drugs, the brain goes into overdrive to compensate, which can lead to convulsions, seizures, or even death.
Tapering methods are used in these cases, such as in benzodiazepine withdrawal. The dosage of a benzodiazepine may be slowly lessened over time, gradually easing the client off. The gradual tapering process tends to happen over the course of months. The exact duration of the taper depends on how long the drugs were taken for and how much was taken each time.
In cases of alcohol abuse, doctors administer disulfiram, a synthetic compound used to make alcohol consumption produce unpleasant aftereffects. It is more commonly known by its brand, Antabuse. Its alternative name is tetraethylthiuram sulfide.
Naltrexone versus Suboxone for opioid addiction
Both medications are effective treatments for controlling heroin and opioid craving. Their difference? Naltrexone (brands ReVia and Vivitrol) is an injection administered once a month, and should be used only after detox. Suboxone (buprenorphine and naloxone) is a daily oral medication that can be used before or after detox.
While detox is a critical first step in the recovery process, it is not an effective treatment on its own. It must be followed by a comprehensive addiction treatment program that primarily includes therapy.
The most common complementary treatment is Cognitive Behavioural Therapy (CBT). It focuses on behavioural and thought patterns, and coping mechanisms to modify thoughts and change compulsive behaviour.
Group therapy involves family, friends, colleagues, counsellors, fellow rehab attendees, and the community. Social support from groups like Alcoholics Anonymous has been proven to have above-average success in combatting relapse.
In seeking more effective treatment for addiction, scientists are developing new technologies that analyze factors contributing to addiction vulnerability more precisely. These involve genetics, among others. They’re improving methods that can manipulate certain circuits in the brain to change the behavioural phenotype of a test subject to being more resilient to addiction. Phenotype refers to the observable characteristics of an organism that result from the interaction of its genotype (total genetic make-up) with the environment.
A noninvasive brain stimulation technique called transcranial magnetic stimulation (TMS) turns off the appeal of alcohol and cocaine to chronic users by changing the brain’s response to them. TMS targets a specific brain region where addiction and rewards processing takes place. The procedure involves scanning patients’ brains using functional MRI to assess their response to triggers, such as seeing a cigarette. TMS significantly reduces the brain’s reactivity to drug cues.
Whatever the treatment method, the path to recovery should be one which the addicted person willingly takes. Coupled with support and encouragement, recovery is usually achievable.
 “The DSM-IV specifier for a physiological subtype has been eliminated in DSM-5, as has the DSM-IV diagnosis of polysubstance dependence.” – and – “Highlights of Changes from DSM-IV-TR to DSM-5”. American Psychiatric Publishing. American Psychiatric Association. 2013. p. 16. Accessed at: http://www.dsm5.org/documents/ changes%20from%20dsm-i v-tr%20to%20dsm-5.pdf
Information on anabolic steroids and cocaine: British Journal of Pharmacology and The Neuropathology of Drug Addictions and Substance Misuse
Statistics:World Drug Report 2019. United Nations Office on Drugs and Crime (UNODC). United Nations publication, E.19.XI.8.
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) https://americanaddictioncenters.org/polysubstance-abuseJuergens, Jeffrey. “What is Polydrug Use?”. Addiction Center. July 23, 2019.
Photo credit: Marco Verch. This picture has a Creative Commons attribution license.