| Mixed addictions are defined as the use of multiple substances in an addictive fashion. It has become increasingly rare for individuals to abuse a single substance in isolation. Because alcohol is legal and widely available, it was once common to find "pure" alcoholics who would never consider abusing other drugs. However, the use of multiple substances is currently the norm among addicts.
Polysubstance abuse is defined as repeated use of at least three groups of substances, excluding caffeine and nicotine, with none of the three groups used more than the others. There are four general patterns of mixed addictions: the indiscriminate use of any mood-altering substance, either alone or in combination; the use of substances with opposing physiological properties such as alcohol and cocaine; the use of drugs with physiologically similar profiles such as tranquilizers and alcohol; and the substitution of one substance perceived as safer or less of a problem for another, such as marijuana for alcohol.
Some mental health professionals consider compulsive gambling, compulsive sexual behaviors, workaholism, and eating disorders to be part of mixed addiction disorder, and believe that adequate treatment should address all compulsive behaviors. An individual with polysubstance addiction continues to abuse multiple substances despite legal or work-related problems caused by substance abuse. For example, such an individual may engage in binge drinking on weekends, obtain codeine prescriptions in order to use more than the originally prescribed dose, snort cocaine several times a month, and smoke marijuana each time cocaine is used.Risk: About half of those individuals with bipolar mood (affective) disorder or schizophrenia may have drug or alcohol problems. As many as 80% of those with post-traumatic stress disorder may abuse alcohol or drugs. Males having biological male relatives with histories of alcohol and/or substance abuse may be predisposed toward single or mixed addictions. Incidence and Prevalence: The Institute of Medicine estimates that that there are approximately 5.5 million individuals in the US who clearly or probably need treatment for drug use disorders, and an additional 13 million who clearly or probably need treatment for alcohol use disorders. Of these, two-thirds are men, and approximately one-third concurrently have more than one substance abuse disorder. |
Source: Medical Disability Advisor
| History: A diagnosis of mixed addiction is based on criteria listed in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision). The individual gives a history of repeated use of multiple substances over the same 12-month period that caused a decline in interpersonal, occupational, and social functioning.
The diagnosis depends on the individual demonstrating at least three or more of the following criteria at any time in the same 12-month period: a need for markedly increased amounts of one or more substances to achieve the desired effect; diminished effects with continued use of the same amounts of a substance; symptoms of withdrawal, including tremors, increased blood pressure, increased heart rate, cravings, sweating, diarrhea, muscle cramps, or fever when use of alcohol, opioids, sedatives, or hypnotics is interrupted; persistent unsuccessful attempts to quit or control substance use; a great deal of time spent in activities related to the use of or recovery from the use of various substances; social, occupational, recreational, or relational activities given up for the sake of substance use; and continued substance use despite knowledge of recurrent physical or psychological problems related to their use. Physical exam: If the individual uses alcohol, physical evidence may include signs of withdrawal such as tremors, sweating, increased blood pressure, or increased heart rate. Examination of the abdomen by touch (palpation) may reveal an enlarged liver (hepatomegaly) or a small hard liver and reddish discoloration of the palms (palmar erythema). A mental status exam may reveal confusion or disorientation. Neurological examination may reveal decreased sensation in the toes and fingers consistent with peripheral neuropathy, or problems with gait and coordination suggesting cerebellar dysfunction. If the individual is in withdrawal from opioids such as heroin, there may be muscle cramps, nausea and vomiting, diarrhea, increased blood pressure, and needle insertion marks on the arms or other body areas. Significant weight loss may accompany use of amphetamines, cocaine, or heroin. Tests: Alcohol abuse leads to elevated blood levels of liver enzymes, including glutamyl transferase, high blood lipids, and/or an anemia showing large red blood cells (macrocytic anemia). A urine drug screen may show the presence of cocaine, marijuana, opioids, codeine, or other substances if the test is performed after the individual recently used a substance. Physiologic effects of chronic substance abuse may include gastrointestinal, cardiovascular, neurological, immunologic, and endocrine involvement. |
Source: Medical Disability Advisor
| Abstinence is the treatment goal. If the mixed addiction includes alcohol use, the individual may benefit from medications in the acute phase of alcohol withdrawal, including benzodiazepines to decrease tremors and reduce or prevent increased blood pressure and heart rate. Other medications may be used for symptomatic treatment of diarrhea or muscle aches. Folic acid, thiamin, and vitamin B12 help counteract vitamin deficiencies.
Some individuals may be admitted to a hospital or a specialized alcohol detoxification unit for the first few days of treatment, whereas others may be treated on an outpatient basis. Alcohol, sedative, hypnotic, anxiolytic, and, sometimes, opioid abuse may require hospitalization to facilitate safe withdrawal.
Other factors that may require inpatient substance abuse treatment are severe anxiety and/or depression or psychotic symptoms lasting beyond 1 to 3 days after abstinence or repeated failures of outpatient treatment. Hospitalization may be necessary if the individual is having severe withdrawal symptoms during detoxification or is violent toward him- or herself or others. A narcotic antagonist such as naltrexone diminishes the effects of alcohol. The drug disulfiram causes an individual to be intolerant of alcohol and can be used to help some individuals remain abstinent.
One approach to heroin treatment is called Ultra Rapid Opioid Detox (UROD) and involves the use of opiate antagonists and general anesthesia, allowing individuals to be safely detoxified within a few hours. This technique greatly shortens the time of detoxification, avoids the pain and other discomforts of withdrawal, allows earlier entry into the rehabilitation phase of a recovery program, minimizes time lost from work and family, and reduces the relatively high percentage of individuals who leave conventional detoxification programs prematurely. However, it is a high-risk procedure that requires careful medical monitoring. Even though the success rate of this 1 to 2 day detoxification process is high, the actual measure of success is whether the individual remains abstinent over a period of time, usually after involvement with traditional outpatient addiction treatment programs.
Addiction recovery occurs in four phases. The acute phase focuses on alleviating symptoms of physiological withdrawal and typically lasts 3 to 5 days. The next phase consists of a 1 month period of abstinence during which the individual focuses on changing behavior. The early remission phase can last up to 12 months, and the sustained remission phase lasts as long as the individual refrains from alcohol or substance use and no longer meets the criteria for substance dependence. Treatment for the 1 month abstinence and early remission phases may include education on the physical, emotional, and mental aspects of addiction and recovery; identification of stressors and stress management skills; training to improve coping skills; assertiveness training; and relaxation training. Cognitive behavioral therapy that focuses on correcting maladaptive attitudes and behaviors can be helpful.
Ongoing structured self-help programs such as Alcoholics Anonymous, Narcotics Anonymous, and Rational Recovery are recommended as an adjunct to treatment services. Regular but random drug screens may be part of the treatment process. It should also be understood that relapse may occur and even be part of the recovery process. |
Source: Medical Disability Advisor
| Some individuals respond to treatment and stay in remission from substance dependence for many years. However, some experience periods of relapse, during which they begin substance use after a period of remission and again meet the criteria for substance dependence. Other individuals can never abstain from substance use and do not experience any periods of remission.
Motivation to change is an important predictor of outcome. Chronic illness because of liver or gastrointestinal complications, neurological disability related to alcohol abuse, or death from overdose, suicide, or homicide may all result from mixed addictions. |
Source: Medical Disability Advisor
| Other psychiatric illnesses may complicate treatment of both the chemical dependency and the other illness (dual diagnosis). Drug abuse may cause psychiatric symptoms, such as the suspiciousness (paranoid psychoses) frequently seen with chronic amphetamine or cocaine abuse. Depression is commonly seen in alcohol, marijuana, or sedative dependence. Sudden withdrawal of alcohol in a habitual user can lead to tremors, anxiety, agitation, hallucinations, grand mal seizures, or death. Excessive, prolonged use of alcohol can damage the stomach lining (gastritis), esophagus (esophageal varices), liver (liver failure, cirrhosis), pancreas (pancreatitis), and heart (cardiomyopathy). Prolonged use can increase the individual's risk of getting liver, gastrointestinal, and other cancers. Individuals who use intravenous drugs such as heroin are at increased risk for contracting hepatitis and HIV. |
Source: Medical Disability Advisor
| Many employers have systems in place for individuals recovering from alcohol or substance dependence disorders that allow them to return to work under special contracts or conditions. These conditions usually include routine or random testing of blood and urine levels for identified substances and work performance and substance abuse treatment guidelines for the recovering individual. Depending upon the nature of the addiction, as well as job-specific issues, an employer may or may not have legal obligations to accommodate a claimed disability relating to an addiction. Legal counsel should be consulted when considering accommodation and return to work.
Temporary work accommodations may include reducing or eliminating activities in which the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote timely and safe transition back to full work productivity.
If the individual has chronic side effects of prolonged alcohol or substance use, such as cardiac, liver, or nervous system damage, restriction to sedentary type activities may be necessary. Opportunities to obtain substances of abuse should be minimized; that is, individuals should not work in establishments serving liquor or in pharmacies where drugs are available. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual display any one of the four general patterns for mixed addictions?
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Was a comprehensive assessment of this type completed on this individual? If not, what areas were omitted?
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Have all underlying medical and psychiatric disorders been identified?
Regarding treatment:
- What does individual's current treatment plan include?
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Would addition of other modalities be beneficial?
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What phase of recovery is individual currently experiencing? Have setbacks occurred?
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Is individual participating in 12-step programs such as Alcoholics or Narcotics Anonymous?
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Was hospitalization required?
Regarding prognosis:
- Is individual currently involved in a support group?
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Does individual participate in a formal support group? What other support systems does individual have in place? Family? Friends? Social?
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Is individual receiving the needed tools, skills, and encouragement to move ahead with his or her life?
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Source: Medical Disability Advisor
| Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000. |
Source: Medical Disability Advisor
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