Alcohol Use Disorder and Polydrug Withdrawal

Withdrawal management for individuals with alcohol use disorder and polydrug use is complicated and the therapeutic approaches are highly reliant upon the substances currently being consumed and the dosages. While it is not possible to cover all approaches specific to alcohol and other substances and in their combinations, some common examples are briefly covered in this section. 

In some situations, patients may only be ready to withdraw from one or two substances. This can often be undertaken in an outpatient setting (Chapter 8). This will require the provision of supportive care and regular monitoring. Any medication would usually be provided via daily supervised dispensing (although if good family support is available, a family member may be prepared to take responsibility for daily supervision of medication).

Nicotine is the most common substance used concurrently by people with alcohol use disorder. Smoking cessation support should always be provided to current smokers as part of overall withdrawal management in all settings. Within public sector treatment services (which are all designated “smoke free” zones) it is usual practice to provide appropriate nicotine replacement therapy for any patients who may be nicotine dependent, including cannabis smokers who mix cannabis and tobacco. Varenicline as a pharmacotherapy is safe and effective in smokers with alcohol use disorder, and some evidence suggests it may be helpful treating both. However, some people are not motivated to stop smoking and may be unwilling to enter a smoke free treatment facility or to adhere to this policy. Pragmatic approach to managing this problem includes open discussion of treatment policies and options, preferencing outpatient management, accepting nicotine replacement for the inpatient stay, or allowing access to a smoking area or periods of leave.

Patients may present in a crisis situation seeking polydrug withdrawal support, such as a family crisis scenario, or a pending court case. For crisis situations it is typically recommended that withdrawal support be provided in an inpatient setting, such as a community detox unit that provides 24-hour monitoring.   

Sometimes, patients may present in an emergency hospital setting and require surgery or other acute medical treatment. Inpatient-monitored withdrawal support entails identifying the substance having greater withdrawal severity risk (usually alcohol, followed by other sedatives) with linkage to ongoing care after discharge. Added caution is suggested for patients with borderline personality disorder presenting in crisis, because such circumstances do not always respond well to inpatient treatment. Therefore, unless underlying serious medical/psychiatric conditions exist, independently requiring an inpatient admission, such patients are recommended for brief crisis intervention. Withdrawal management as described in Chapter 8 should be planned for a later time, when a crisis setting does not prevail. 

While sedative drugs may provide some benefit to overall withdrawal symptoms, the higher the overall estimated daily exposure to alcohol and other sedatives, the higher the likely withdrawal severity. Alcohol is the substance that is most likely to require withdrawal treatment, and is treated with benzodiazepines (see Chapter 8). When providing such treatment for a patient also consuming multiple sedative drugs, the alcohol withdrawal is likely to be more severe and thus require larger benzodiazepine doses. Typically, a longer acting benzodiazepine like diazepam is given in a sequential loading dose procedure (Chapter 10). 

When stimulants are a part of a polydrug use mix, these drugs usually do not require additional specific pharmacotherapy treatment because sudden discontinuation of heavy regular stimulant use is likely to be associated with sedation.

Both alcohol and stimulants are associated with increased cardiovascular risk, so in a treatment setting, people with heavy use of alcohol and stimulants should always receive screening for cardiovascular effects. While hypertension is a common finding in acute presentations, stress and withdrawal typically increases blood pressure and therefore measurements taken after withdrawal has abated, are generally more reflective of any underlying hypertensive state.