Polydrug Abuse
Although drug abusers often report a preference for a particular drug, such as alcohol or opiates, the concurrent use of other drugs is common. Multiple drug use often involves substances which may have different pharmacologic effects from the preferred drug. Concurrent use of such dissimilar compounds as stimulants and opiates or stimulants and alcohol is not unusual. The diversity of reported drug use combinations suggests that achieving some perceptible change in state, rather than any particular direction of change (stimulation or sedation), may be the primary reinforcer in poly drug use and abuse.
A practical determinant of polydrug use patterns is the relative availability and cost of the drugs. There are many examples of situationally determined drug use patterns, including the fact that soldiers who became dependent on heroin in Vietnam seldom continued heroin use after separation from military service. However, a significant number of Vietnam heroin addicts abused alcohol and became alcohol-dependent when they returned to the United States. Alcohol abuse, with its attendant medical complications, is one of the most serious problems encountered in former heroin addicts participating in methadone maintenance programs.
The physician must recognize that perpetuation of polydrug abuse and drug dependence is not necessarily a symptom of an underlying emotional disorder. Neither alleviation of anxiety nor reduction of depression accounts for initiation and perpetuation of polydrug abuse. Severe depression and anxiety are as frequently the consequences of polydrug abuse as they are the antecedents. There is also evidence that some of the most adverse consequences of drug use may be reinforcing and contribute to the continuation of polydrug abuse.
Adequate treatment of polydrug abuse, as well as other forms of drug abuse, requires innovative and eclectic programs of intervention. The first step in successful treatment is detoxification, a process which may be difficult because the patient has abused several drugs with different pharmacologic actions (e.g. alcohol, opiates, and cocaine). Since patients may not recall or may deny simultaneous multiple drug use, diagnostic evaluation should always include urinalysis for qualitative detection of psychoactive substances and their metabolites. Treatment of polydrug abuse requires hospitalization or inpatient residential care during detoxification and the initial phase of drug abstinence. When possible, specialized facilities for the care and treatment of chemically dependent persons should be used. Outpatient detoxification of polydrug abuse patients is likely to be ineffective and may be dangerous.
As in the treatment of alcohol abuse, no single therapeutic modality has been shown to be uniquely effective in inducing remission. Polydrug abuse is a chronic disorder with an unpredictable pattern of remission and recrudescence. Therapeutic management of chronic disorders such as cardiac or neoplastic disease should serve as a model for helping the person with polydrug abuse problems. Even temporary remissions with attendant physical, social, and psychological improvements are preferable to the continuation or progressive acceleration of polydrug abuse and its related adverse medical and interpersonal consequences. In polydrug abuse, as in most chronic disorders, definitive “cures” rarely occur. The concerned physician should continue to assist polydrug abuse patients throughout the cyclic oscillations of this complex behavior disorder, recognizing that resumption of drug use may be the rule rather than the exception.