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Polysubstance Abuse and Addiction

Polysubstance use or abuse is a general term for the consumption of more than one drug over a period of at least 12 months, simultaneously or at different times for either therapeutic or recreational purposes. In the substance abuse context, it usually refers to the use of multiple illicit drugs, however, it can also apply to prescription medications used for nonmedical purposes.1 People often use multiple substances in an attempt to enhance the effect of a single drug to create a more intense high.

In 2008, the term polysubstance appeared widely in the media in context with the high profile “Preppie Killer” case. Robert Chambers used psychiatric “polysubstance abuse” as his defense. His defense team described Chambers’ lifelong addiction to heroin, cocaine and prescription drugs. According to his lawyer, Chambers was using 10 to 12 bags of heroin a day, smoked crack and pot and abused the painkiller Dilaudid.2

Polysubstance Abuse Demographics

In 2013, large-scale research survey on polysubstance use was conducted in the U.S., U.K., Australia, Denmark and Latin American countries. The survey found that among teenagers, polysubstance use was commonly restricted in scope, but the prevalence use rate was high. In teens ages 12-17, there was a lifetime prevalence use rate of 18 percent, however, in teenagers younger than 16, the lifetime prevalence use rate was nearly twice as high at 34 percent.3

The abuse of multiples substances is especially prevalent in treatment-seeking substance abusers, men who engage in high-risk sexual behaviors such as sex with other men, HIV-infected men who engage in sex with other men and transgender women.3

Older adults are more likely to be prescribed long-term and multiple prescriptions, and some experience cognitive decline, which can lead to improper use of medications and polysubstance abuse.4 The combination of alcohol and medication misuse has been estimated to affect up to 19 percent of older Americans. An estimated 25 percent of older adults use prescription psychoactive medications that have the potential for misuse or abuse.5

A 2000 study on 243,523 people admitted to opiate treatment centers for heroin use reported the use of other drugs. An estimated 42.7 percent of clients reported only using heroin. While the average number of substances used (per admission) was 1.8, some substances had statistically significant usage rates.6

  • Alcohol: 23.3 percent
  • Non-smoked cocaine: 22.2 percent
  • Marijuana/hashish: 12.1 percent
  • Smoked cocaine: 12.1 percent
  • Other opioids: 4.3 percent
  • Tranquilizers: 3.0 percent
  • Methamphetamine/amphetamine: 2.8 percent

Co-Occurring Mental Health Issues

In people who abuse multiple substances, there are higher levels of general psychological distress and symptoms of anxiety and depression are more prevalent. Alcohol users who are classified as having concurrent illicit drug use are more likely to have generalized anxiety and major depressive disorders. Treatment-seeking people who use marijuana with other substances have higher levels of depression, anxiety, manic excitement and more positive psychotic symptoms than marijuana users who use no other illicit substances.3 One survey reported that an estimated 72 percent of adolescent marijuana users presented with two or more psychiatric disorders when starting treatment.7

Detoxification for Polysubstance Abuse and Addiction

The first step in tackling polysubstance abuse is detoxification. Detox is more complex and problematic with polysubstance addiction for several reasons. An accurate history of total substances abused must be obtained, and the client may not be able or willing to provide complete details. Determination of the actual substances being used typically requires breath, urine and/or blood screening tests.

Some clients can be treated on an outpatient basis, while others including those with alcohol, sedative, hypnotic, opioid and anxiolytic abuse may require hospitalization or inpatient detox. Repeated failures to abstain or severe anxiety, depression or psychotic symptoms lasting 1-3 days after abstinence may also require inpatient substance abuse treatment.

Treatment for mixed addiction that also includes alcohol may include benzodiazepines during the acute phase of alcohol withdrawal. Benzodiazepines can help decrease tremors and prevent or reduce an increase in heart rate and blood pressure.8 Medication to treat symptoms of diarrhea or muscle aches may also be prescribed. Administration of thiamine and vitamin B-12 may counteract vitamin deficiencies caused by alcohol.9

Treatment Evaluation Factors

The length of treatment is determined by a number of factors including:

  • The duration of abuse
  • Type of substance dependence
  • Presence of organ damage
  • Co-occurring mental illness
  • Desire to change and willingness to undergo treatment
  • Adequacy of social support system
  • Plans for ongoing care

Post Detox Rehab

After drug-use patterns and substances have been identified, a thorough psychological evaluation is key. Adequate time must be spent on treatment components in addition to detox including a thorough history evaluation and knowledge of any co-occurring psychiatric conditions.

Although there are many different aspects of treatment, this is generally implemented in four phases, as designated by the National Institute on Drug Abuse. The four phases are treatment initiation, early abstinence, maintaining abstinence and advanced recovery.10

The first phase focuses on alleviating symptoms or physiological withdrawal. During the second phase, the client will continue to experience withdrawal symptoms, physical cravings, psychological dependence and a host of triggers that can elicit relapse. However, at this point they are ready to work on coping skills with their addiction counselor to deal with these issues. After about 90 days of continual abstinence, clients move on to maintaining abstinence. It is usually at this stage that clients will transition from residential programs to outpatient rehab. The final stage is reached when a client has achieved complete abstinence for five years.10

Cognitive behavioral therapy (CBT): More than 1,000 outcome studies have been performed on the use of CBT as a primary and adjuvant therapy for psychiatric disorders, as well as substance abuse. CBT helps people learn to identify, challenge and transform distorted beliefs and negative, irrational thoughts into ones that are empowering, realistic and positive.11

Self-help programs: Alcoholics Anonymous, Narcotics Anonymous, and other groups are recommended as an ongoing adjuvant therapy. Part of the recovery program may include regular and random drug screenings.

Polysubstance Addiction – Is There Hope?

Combating addiction to multiple substances is more difficult than one drug, however, it is possible to overcome. The likelihood of success depends on an individual’s determination and discipline in abstaining completely from the use of any substances. There may be repeated relapses before stability becomes a part of the recovering person’s life. Like any other addiction, long-term recovery after polysubstance abuse requires ongoing diligence and participation in a support network. Belief in one’s self and the ability to stay clean and sober are two important building blocks in recovery.

  1. Connor JP, Gullo MJ, White A, Kelly AB. Polysubstance use: diagnostic challenges, patterns of use and health. Curr Opin Psychiatry. 2014 Jul;27(4):269-75. doi: 10.1097/YCO.0000000000000069.
  2. Polysubstance use: diagnostic challenges, patterns of use and health. Medscape website. http://www.medscape.com/viewarticle/826373_3 Published July 2014, Accessed July 26, 2016.
  3. Preppy Killer to Use Drug-Psychiatric Defense. Gothamist website. http://gothamist.com/2008/03/12/preppy_killer_t.php Published March 12, 2008. Accessed July 25, 2016.
  4. Prescription Drug Abuse. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/research-reports/prescription-drugs/trends-in-prescription-drug-abuse/older-adults Updated November 2014. Accessed July 26, 2016.
  5. Specific Populations and Prescription Drug Misuse and Abuse. Substance Abuse and Mental Health Services Administration website. http://www.samhsa.gov/prescription-drug-misuse-abuse/specific-populations Updated October 27, 2015. Accessed July 26, 2016.
  6. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.) Chapter 11. Treatment of Multiple Substance Use. http://www.ncbi.nlm.nih.gov/books/NBK64146/ Accessed July 26, 2016.
  7. Chan YF, Dennis ML, Funk RR. Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment. J Subst Abuse Treat. 2008 Jan; 34(1): 14–24. Published online 2007 Jun 15. doi: 10.1016/j.jsat.2006.12.031.
  8. Sachdeva A, Choudhary M, Chandra M.Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res. 2015 Sep;9(9): VE01–VE07. Published online 2015 Sep 1. doi: 10.7860/JCDR/2015/13407.6538.
  9. Chopra K, Tiwari V. Alcoholic neuropathy: possible mechanisms and future treatment possibilities. Br J Clin Pharmacol. 2012 Mar; 73(3): 348–362. Published online 2011 Oct 11. doi: 10.1111/j.1365-2125.2011.04111.x.
  10. The Four Stages of Alcohol and Drug Rehab Recovery. Very Well website. https://www.verywell.com/the-four-stages-of-alcohol-and-drug-rehab-recovery-67869 Updated June 5, 2016. Accessed July 26, 2016.
  11. What is Cognitive Behavioral Therapy (CBT)? Beck Institute website. https://www.beckinstitute.org/get-informed/what-is-cognitive-therapy/ Accessed June 26, 2016.

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