Polysubstance use in the U.S. Opioid Crisis

A new article co-authored by IBH President Robert L. DuPont, MD and Wilson M. Compton, MD, MPE and Rita J. Valentino of the National Institute on Drug Abuse (NIDA) urges new research on the prevalence and reasons for polysubstance use to inform and improve both the prevention and treatment of opioid use disorders. The current approach to substance use disorders (i.e., addiction) is substance-specific which neglects to address the common issue of polysubstance use.

Published in Molecular Psychiatry, authors highlight the overlap of substances used by American adults across the lifetime, noting, “as a general principal, the more widely a drug is used, the higher the percentage of users who do not use other drugs; and, the less widely used, the more likely a drug is to be used with other drugs.”

Fig. 1: Overlap of substances used across the lifetime. Weighted lifetime prevalence of substance use and mean number of other substances ever used by adults age 18 and older in the United States (n = 51,000; Source: 2018 U.S. National Survey on Drug Use and Health [adapted from Eric Wish, University of Maryland, Center for Substance Abuse Research]).

Abstract: Interventions to address the U.S. opioid crisis primarily target opioid use, misuse, and addiction, but because the opioid crisis includes multiple substances, the opioid specificity of interventions may limit their ability to address the broader problem of polysubstance use. Overlap of opioids with other substances ranges from shifts among the substances used across the lifespan to simultaneous co-use of substances that span similar and disparate pharmacological categories. Evidence suggests that nonmedical opioid users quite commonly use other drugs, and this polysubstance use contributes to increasing morbidity and mortality. Reasons for adding other substances to opioids include enhancement of the high (additive or synergistic reward), compensation for undesired effects of one drug by taking another, compensation for negative internal states, or a common predisposition that is related to all substance consumption. But consumption of multiple substances may itself have unique effects. To achieve the maximum benefit, addressing the overlap of opioids with multiple other substances is needed across the spectrum of prevention and treatment interventions, overdose reversal, public health surveillance, and research. By addressing the multiple patterns of consumption and the reasons that people mix opioids with other substances, interventions and research may be enhanced.

Compton, W.M., Valentino, R.J. & DuPont, R.L. (2021). Polysubstance use in the U.S. opioid crisis. Molecular Psychiatry, 26, 41–50. https://doi.org/10.1038/s41380-020-00949-3

Should physicians with opioid use disorders be offered an option of opioid agonist treatment?

A new article published in the Journal of the Neurological Sciences reviews neuropsychological impairment associated with substance use by physicians; describes common neurocognitive deficits following use of various drug classes; and reviews the neurocognitive impact of pharmaceutical treatments for opioid use disorder (OUD). Authors emphasize the importance of continued testing/monitoring for physicians with substance use disorders (SUDs) following acute treatment.

In response to this review article, Robert L. DuPont, MD and Mark S. Gold, MD authored a commentary published in Clinical Psychiatry News, noting that to understand the controversy over the use of medication-assisted treatment (MAT) in the care management of physicians with OUDs requires: 

• An understanding of state PHPs and how those programs oversee the care of physicians diagnosed with SUDs, including OUDs; 

• Recognition that medical practice in relationship to SUDs is treated by state licensing boards as a safety-sensitive job; and

• An understanding of the historical context of the unique system of care management for physicians which began in the early 1970s.

"Dr. Polles and colleagues call attention to the unique care management of the PHP for all SUDs, not just for OUDs, because the PHPs set the standard for returning physicians to work who have the fitness and cognitive skills to first do no harm. They emphasize the importance of making sustained recovery the expected outcome of SUD treatment. There is a robust literature on the ways in which this distinctive system of care management shows the path forward for addiction treatment generally to regularly achieve 5-year recovery. The current controversy over the potential use of buprenorphine and buprenorphine plus naloxone in PHPs is a useful entry into this far larger issue of the potential for PHPs to show the path forward for the addiction treatment field." Read more.