Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

11. Polysubstance Use, Abuse, and Dependence 263TREATMENT CONSIDERATIONSAt its simplest, treatment of patients with chronic multiple SUDs requires afocus upon each disorder separately, in addition to providing patients with acoherent overall rationale and approach to addiction treatment. Although multipleSUDs have a net negative impact on treatment outcome, Abellanas andMcLellan (1993) have shown that patients with multiple SUDs report generallysimilar motivation for change across drugs of abuse, meaning that theirdesire to modify their substance use remains consistent across substances. Anadditional issue is the specific impact of other substance use upon recovery for aparticular SUD. Treatment is thus best constructed with a bottom-up approach,using evidence-based approaches where available (Rosenthal, 2004), ratherthan assuming that optimal treatment should be largely psychotherapeutic orpharmacotherapeutic. For example, there is a clear evidence base for the useof methadone as an agonist therapy for stabilization of opioid dependence(Ciraulo, 2003). However, there is not good evidence that an adequate dose ofmethadone for treating opioid dependence will suffice in treating cocaine abuseor dependence. Since there is no approved pharmacotherapy for cocaine usedisorders at present, the optimal therapy should come from the behavioraltreatments, which also have an evidence base. As such, the approach to treatingpatients with opioid dependence and cocaine dependence should have bothpharmacotherapeutic and psychotherapeutic components.In the acute setting, multiple SUDs present the treatment team with significantchallenges. Given a patient’s complicated history of recent and chronicuse of multiple substances, the clinician in the emergency room or detoxificationunit often struggles to make treatment priorities out of a constellation ofsigns and symptoms that may be the result of intoxication or withdrawal from anumber of substances. Given the frequent occurrence of multiple substance usediagnoses (particularly between alcohol and other drugs), any attempt to attributeobserved findings associated with comorbid substance use to a single substance,or class of substances, is often difficult, if not impossible. Intoxicationfrom stimulants may result in psychotic symptoms, but so does withdrawal fromsedatives. Lethargy is not only a classic sign of opioid intoxication but also aconsequence of stimulant withdrawal. A patient who currently uses both benzodiazepinesand crystal methamphetamine, and presents with seizures, may beeither acutely intoxicated with methamphetamine or suffering from severebenzodiazepine withdrawal, or both. Furthermore, the serious psychosocialcomplications of multiple SUDs add significantly to the difficulty in treatingthe already confusing biological manifestations of the illness. As in the case ofrelapse prevention, the successful management of acute multiple substance userelies primarily upon identification and treatment of each intoxication andwithdrawal syndrome separately. For example, patients with serious withdrawalfrom heroin and alcohol typically require both opioid agonists (e.g., methadone