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B3: 9 Polydrug Use HO1
Responding to polydrug use
Responding to the needs of a person who engages in polydrug use is one of many common
situations encountered in general practice. It is easy to be overwhelmed by the patient who
uses several drugs, and the multiple associated physical, social and psychological
problems. In providing a framework for thinking about this topic, it is important to
remember that the situation is even more overwhelming for the patient. Adopt a global
perspective and a long term time scale in helping to achieve minimal harm – and, where
accepted by the patient, a return to safer levels of use.
Usually, it is of little use to try and get patients off a number of drugs simultaneously;
negotiate with them about their priorities and the most significant risks to their health and
well being. Generally, try approaching polydrug use sequentially, acknowledging the need
to minimise harm as effectively and quickly as possible. The ability of drugs to potentiate
or counteract each other should be appreciated – some people use various combinations of
drugs deliberately. For example, alcohol and benzodiazepines are both CNS depressants,
whereas others may combine psychostimulants and cannabis as they believe (quite
inaccurately) that the effects of one will “oppose” or negate the other. At other times,
patients may use one drug to treat the effects of withdrawal of another drug, hence making
the withdrawal from any one drug more complex.
Some patients may “transfer” their dependence from one drug to another during the
treatment process. Faced with the reality of giving up one drug, their attention may focus
on another. Giving up amphetamines, for example, may lead to increased benzodiazepine
use, at least in the short term. As the clinician, we need to acknowledge – and share with
the patient – the likelihood of these fluctuations and be prepared to ride them out. We need
to be cognisant of the range of problems that can be associated with any one drug in order
to be “on top” of the situation with patients changing between several drugs. Take the long
view – and reassure the patient they will get the long term support necessary to achieve
overall goals.
The general practitioner should know the potential range of harms associated with each
type of drug use.
The general practitioner should know how the main classes of drugs tend to interact with
each other.
The general practitioner should be able to prioritise their approach to polydrug use to
recognise the most hazardous (in terms of immediate harm to the patient) drug use first.
Resource Kit for GP Trainers on Illicit Drug Issues
Part B3 Clinical Complexity: Polydrug use
Practical guidelines
Prioritising your approach means trying to minimise the risk and harm to the patient, for
example, try addressing injecting drug use complications before addressing other issues.
While you need to personalise your approach, generally deal with the problems that result
in most harm first. It may be that behaviours or risks associated with the use of a particular
drug may require your immediate attention rather than focussing on the drug itself. Other
than this, the approach given to different types of drugs should progress as outlined in the
preceding chapter.
We are trying to assess the relative risk of each element of the patient’s alcohol and drug
use. Remember that they may be at different “stages of change” for each drug – they may
be actively trying to change their use of amphetamines, contemplating reducing their
drinking, but not even acknowledging that their tobacco use is a health risk simultaneously.
Work your way from one to another, and take a long term outlook.
Relapse issues may be magnified with polydrug situations – keep pointing out to your
patient the small gains they continue to make and emphasise the importance of continuing
to attend regularly for support, monitoring and follow up.
Polydrug use is often a situation where early referral for a specialist opinion can help to
guide a community based care plan enacted by the general practitioner. “Shared care”
models of treatment between general practice and drug and alcohol agencies are now being
tried with increasing success in a variety of settings – know where to get help and know
how to use it.
Source: Wales, S., Brough, R. & Dammery, D., 1995?, Drink, Drugs and Doctors: A guide to quality care.
Standards and Guidelines for General Practice (Draft), Draft Standards and Guidelines Working Party, The
Royal Australian College of General Practitioners, Carlton, Victoria.
Resource Kit for GP Trainers on Illicit Drug Issues
Part B3: Clinical Complexity: Polydrug use