Treatment Considerations

At its simplest, treatment of patients with chronic multiple SUDs requires a focus upon each disorder separately, in addition to providing patients with a coherent overall rationale and approach to addiction treatment. Although multiple SUDs have a net negative impact on treatment outcome, Abellanas and McLellan (1993) have shown that patients with multiple SUDs report generally similar motivation for change across drugs of abuse, meaning that their desire to modify their substance use remains consistent across substances. An additional issue is the specific impact of other substance use upon recovery for a particular SUD. Treatment is thus best constructed with a bottom-up approach, using evidence-based approaches where available (Rosenthal, 2004), rather than assuming that optimal treatment should be largely psychotherapeutic or pharmacotherapeutic. For example, there is a clear evidence base for the use of methadone as an agonist therapy for stabilization of opioid dependence (Ciraulo, 2003). However, there is not good evidence that an adequate dose of methadone for treating opioid dependence will suffice in treating cocaine abuse or dependence. Since there is no approved pharmacotherapy for cocaine use disorders at present, the optimal therapy should come from the behavioral treatments, which also have an evidence base. As such, the approach to treating patients with opioid dependence and cocaine dependence should have both pharmacotherapeutic and psychotherapeutic components.

In the acute setting, multiple SUDs present the treatment team with significant challenges. Given a patient's complicated history of recent and chronic use of multiple substances, the clinician in the emergency room or detoxification unit often struggles to make treatment priorities out of a constellation of signs and symptoms that may be the result of intoxication or withdrawal from a number of substances. Given the frequent occurrence of multiple substance use diagnoses (particularly between alcohol and other drugs), any attempt to attribute observed findings associated with comorbid substance use to a single substance, or class of substances, is often difficult, if not impossible. Intoxication from stimulants may result in psychotic symptoms, but so does withdrawal from sedatives. Lethargy is not only a classic sign of opioid intoxication but also a consequence of stimulant withdrawal. A patient who currently uses both benzo-diazepines and crystal methamphetamine, and presents with seizures, may be either acutely intoxicated with methamphetamine or suffering from severe benzodiazepine withdrawal, or both. Furthermore, the serious psychosocial complications of multiple SUDs add significantly to the difficulty in treating the already confusing biological manifestations of the illness. As in the case of relapse prevention, the successful management of acute multiple substance use relies primarily upon identification and treatment of each intoxication and withdrawal syndrome separately. For example, patients with serious withdrawal from heroin and alcohol typically require both opioid agonists (e.g., methadone or buprenophine) and benzodiazepines (e.g., chlordiazapoxide or lorazepam), with particular attention to potential synergistic effects between the two classes of medications.

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Alcohol No More

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