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Why Polysubstance Use Creates Complex Challenges in Recovery
We’ve all read the warning labels on medications, cautioning us against taking them in combination with other substances. Maybe you’ve even experienced the effects of accidentally combining medications without realizing it.
But when the combination of drugs and/or alcohol is intentional, it results in a dangerous and complex situation. For those with a substance use disorder (SUD), particularly, a polysubstance addiction—a dependency on multiple substances—risk of overdose significantly increases, as well as a wide range of health complications, including heart disease, dangerously high or low blood pressure, liver disease, and stroke.
Polysubstance use (PSU) is a growing problem. Most patients who come through the door of our treatment center today have a polysubstance addiction. While some are hesitant or even refuse to admit it, there’s no denying it when it shows up on a routine intake toxicology screening. Some patients even pretend to be surprised when we find multiple substances in their screening. Others seem genuinely shocked, not realizing their pills or heroin had been laced with fentanyl.
Dangerous Combinations Create Complex Situations
The motives for PSU can vary widely. Some people combine “complementary” substances to enhance the effects of the initial drug—opioids plus benzodiazepines, for example, or opioids plus alcohol for a greater feeling of relaxation.
Others use conflicting drugs to counteract one another. For example, because methamphetamine can stay in your system for up to a week causing prolonged stimulation and agitation, some people turn to benzodiazepines or alcohol to relax and come down off of the methamphetamine high. We also often see the use of marijuana and alcohol in combination with other drugs, and even some over-the-counter medications as well, such as Nyquil, Tylenol PM, or even Mucinex. The presence of multiple substances is not only much more dangerous for the patient, but it creates significant complexities at all stages of addiction treatment and recovery.
Difficult Detox
As part of the initial detoxification process, a clear picture of all substances in play is a must, as it can drastically change the way care is administered. Recently, a gentleman came into our center for treatment. He tested positive for opioids, alcohol, and cocaine, a complex combination that required a specific protocol. The symptoms and treatment for withdrawal can be quite different for each substance, which makes detox symptoms much tougher to treat and more difficult for the patient.
When there’s a risk of overdose, PSU can have a major impact on survival and recovery. In fact, half of all drug overdoses involve multiple substances. Administering Narcan only works to reverse the effects of opioids like Vicodin and fentanyl, but if alcohol or cocaine are also in play, Narcan may not provide the life-saving treatment expected, creating a false sense of hope for first responders, family members, or anyone else in a position to administer it. Loved ones and caregivers need to be aware of the risk of Narcan failure in the presence of multiple substances and be prepared to get additional help immediately in the event of a suspected overdose.
Treatment Challenges
During treatment, PSU can be complicated by additional co-occurring disorders, such as depression, anxiety, and other mental health challenges. As treatment professionals, we must understand that patients turn to substances to self-medicate, and to avoid the feelings of pain, challenges, or discomfort.
Getting treatment for polysubstance use is going to be uncomfortable by its very nature, so we must first address the dangerous behavior of combining substances. Then, we can focus on helping patients learn other ways to cope and push through the discomfort toward a better, more sustainable, and healthier outcome.
Polysubstance Use Recovery
Those living in recovery after SUD treatment are at particular risk of PSU, as some operate under the false assumption that they can indulge in alcohol or marijuana, perceiving these to be low-risk or not “real” drugs. But this attitude and behavior is dangerous in recovery. Alcohol is a depressant and marijuana often has depressant effects. Before you know it, relapse takes place and PSU takes hold. As treatment providers, it’s imperative that we warn patients of the dangers associated with replacing one drug with another and that they must abstain from all substances to stay clean, sober, and in recovery.
One of the biggest dangers of PSU is that those living in active addiction have very little or no sense of risk or self-preservation. With their entire being often wrapped up in getting their next fix, and a progressively better fix than the last, they aren’t of sound mind to understand or care about the risks of these deadly combinations.
As with any SUD—whether it’s one or many—we as providers must encourage patients to continue their care after treatment, including psychiatric or behavior therapy, support groups, and recovery meetings. Those in recovery should discuss their PSU with their sponsors and peers in group sessions, leveraging their support to help them remain accountable and on the road to recovery.
Courtney Messina, MA, LPC, LCDC, is clinical director at Greenhouse Outpatient Treatment Center, an American Addiction Centers facility.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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