Treatment

The treatment of the polydrug user presents a particular challenge to the clinician. The simultaneous and concurrent use of multiple drugs may increase the level of dependence, increase drug tox-icities, worsen medical and psychiatric comorbidities due to the drugs, and intensify withdrawal signs and symptoms upon cessation of drug use. The basic principles of treatment of polydrug use are similar to those for the treatment of any single psychoactive-substance dependence. Patients require a complete medical and psychiatric assessment, treatment of active problems, detoxification, then rehabilitation with attempts to reduce subsequent use of the drugs. One of the complications of treating polydrug users is that the patient's history may be unreliable— many cannot remember what they have used and others do not know the identity of drugs they have purchased on the street.

In providing treatment for the polysubstance user, there are two options: (1) sequential treatment for the dependencies, with initial treatment of the major dependency or the dependency with greater morbidity; or (2) simultaneous treatment of all dependencies. Unfortunately, few objective data exist as to which type of treatment is optimal for which patients. Most clinicians rely on their own experience, the capabilities of the treatment setting, and the wishes of the patient. One rule of thumb that has been suggested for complex detoxifications is to focus initially on the CNS depressant drug(s) and not be overly concerned with the opioid component. The patient can be stabilized with regard to the opioid with methadone, and given phenobarbital to prevent the potentially life-threatening symptoms of sedative withdrawal.

The treatment of polysubstance dependence often involves more than one type of treatment modality. A common example is an alcohol-dependent, opioid-dependent, cigarette smoker who is receiving Methadone Maintenance for opioid dependence, abstinence-oriented treatment for alcoholism, and no specific treatment for nicotine dependence. The different treatment philosophies— methadone substitution, abstinence, and no treatment—necessarily conflict. In such cases, good communication and flexibility among the various treatment providers and with the patient are important to ensure optimal, coordinated treatment.

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