Treatment of Multiple Substance Use and Dependencies

Multiple substance use has become increasingly prevalent in many countries, and with it there has been an increase in the proportion of treatment-seeking alcoholics who have multiple dependencies. The pattern of multiple drug use depends on a variety of factors, including the cultural setting, the availability of different substances, and the age of the substance user. A pattern of tobacco and illicit drug use, for example, is common among young adult heavy drinkers.

The drugs most frequently implicated with alcohol dependence are cocaine, opioids, cannabis, benzodiazepines, and nicotine. In general, the presence of multiple drug use in persons with alcohol dependence is associated with more severe dependence, worse retention in treatment, and poorer outcomes (Edwards et al, 2003). Unfortunately, there has been little research on the treatment of multiple drug use, and virtually no attention to the sequencing of interven­tions in persons dependent on two or more substances.

Is it better, for example, to treat multiple substance use simultaneously or should individual substances be addressed sequentially? In a study of cocaine- and alcohol- dependent patients (Carroll et al, 2000), simultaneous treatment with disulfiram was associated with better treatment retention and abstinence from both substances, especially when combined with out-patient psychotherapy. But in the case of co-occurring dependence on alcohol and nicotine, research suggests that patients prefer sequential treatment and simultaneous cessation therapy can nega­tively impact alcohol use outcomes (Kodl etal, 2006).

Treatment Matching and Patient Placement. In response to concerns about the inappropriate use of expensive residential treatment, patient placement cri­teria have been applied in some countries to standardize the way in which patients are assigned to different types and intensities of care. The Patient Placement Criteria for the Treatment of Substance-Related Disorders, of the American Society of Addiction Medicine (ASAM) provides detailed guidelines for different levels of care, including detox­ification, outpatient, and residential care.

The decision to refer the patient to a particular level of care is based on the following considerations: Acute intoxication and withdrawal, biomedical conditions, emotional/behavioral conditions, acceptance of treatment, relapse potential, and recovery environment.

Another approach to patient placement is based on the notion that patients should initially be matched to the least intensive level of care that is appropriate, and then stepped up to more intensive treatment settings if they do not respond. This approach is consistent with the ASAM criteria, which specify that residential treatment should not be recommended unless the patient has failed at outpatient treatment.

Another approach is called treatment matching, which relies on the cumulative evidence of research to suggest the treatment modalities most likely to produce favorable outcomes with different types of patients. In one large-scale study of treatment matching, patients with certain characteristics (e.g., severe dependence, high levels of anger, social networks that support drinking) responded marginally better to certain types of therapy (e.g., Twelve Step Facilitation, motivational enhancement, cognitive behavioral therapy, respectively) (Babor and Del Boca, 2003). Other research (McLellan et al., 1993) suggests the importance of including psychological and social services within specialized treatment facilities in order to meet the diverse psychosocial needs of alcohol-dependent patients.