Assessment and Treatment Plans

Initial assessment should be comprehensive and include a medical, psychological, social and a broad substance use history (Chapter 4). Quantity frequency estimates of alcohol and other drug use must consider that alcohol use is often related to other drug use, for example, a person may increase their use of benzodiazepines when alcohol is not available. Medical and psychiatric comorbidity should be assessed, and risk stratification undertaken to ascertain which substance/s should be considered as priority for management. To do this, the following should be obtained: 1) the patient’s stated treatment goals, 2) a mental status assessment, and 3) physical examination, the latter two aspects requiring a particular focus on identification of comorbidity. Often, for this reason and because of the complexity of the alcohol use disorder and polydrug use, assessment is better performed after a detoxification intervention in a managed setting. When conducting any comprehensive assessment, it is an opportune time to undertake a medication reconciliation to identify what patient medications are deemed essential to continue, and similarly which medications can be reduced, withdrawn, or referred for other specialist advice.   

Recognising that alcohol use disorder and polydrug use is frequently a condition associated with comorbidity, an essential consideration in any treatment plan is to outline how underlying comorbid conditions will be managed when undertaking an elective withdrawal and subsequently after the withdrawal phase. A commonly encountered problem in this setting is that some people change their mind about the initial treatment goal/s during or after the polydrug detox period and begin to seek additional dosing with another drug to substitute (e.g. alcohol dependent person also has chronic pain and is prescribed opioids and pregabalin, but after a required alcohol detox, now requests increases in opioid analgesic doses). Treatment planning before entering the withdrawal phase needs to include contingencies to manage any use of other/additional medication.   

It is important to understand the pattern of alcohol and substance use, in order to determine which substances may be implicated in relapse to other substance use. For example, as alcohol use is often associated with tobacco smoking, if a patient wishes to undertake smoking cessation, an important part of relapse prevention involves concurrently addressing the alcohol use, due to the potential relationship with smoking outcomes. 

It is common amongst individuals with alcohol use disorder and polydrug use to substitute substances, such that if one drug may be withdrawn (either intentionally, as a part of a treatment strategy, or involuntarily) another substance is substituted to replace the missing effect of the withdrawn drug. This must be considered when planning dose reductions, or even withdrawal, of one or more substances for individuals with alcohol use disorder and polydrug use. While initially reducing or withdrawing a substance may be a patient’s preferred treatment goal and also be medically advisable, a later consequence may be replacement with another substance or pharmacotherapy. Integration of care, maintaining a single prescriber, or regular communication between prescribers, is helpful. 

Chapter Recommendation Grade of recommendation
20.1 All patients with alcohol-use disorders should be screened for other substance use using quantity–frequency estimates, or through structured screening instruments such as the ASSIST questionnaire. GPP
20.2 Polydrug dependence is typically associated with higher levels of physical, psychiatric and psychosocial comorbidity. Comprehensive treatment plans should address use of alcohol and other drugs together, taking into account comorbidity. GPP
20.3 Communication between clinicians is essential where more than one is involved particularly more than one prescriber. GPP