12 - Concurrent alcohol and substance use disorder

Concurrent alcohol and substance use disorders

Addictions and substance misuse CHAPTER 4 ­healthcare professionals and likes to follow up on pregnancies that require alcohol ­detoxification. Specialist advice should always be sought. (See also Chapter  7.) No relapse prevention medication has been evaluated in pregnancy.9 Children and adolescents The number of young people who are dependent and needing pharmacotherapy is small, but for those who are dependent there should be a lower threshold for admission to hospital. Doses of chlordiazepoxide for medically assisted withdrawal may need to be adjusted, but the general principles of withdrawal management are the same as for adults. All young people should have a full health screen carried out routinely to allow identification of physical and mental health problems. Relapse prevention medications are not licensed in the under 18 population due to lack of evidence. The evidence base for acamprosate, naltrexone and disulfiram in 16–19-­year-­olds is evolving,9 but ­naltrexone is best supported in this age group.39–41 Older adults For older adults, there should be a lower threshold for hospital admission for medically assisted alcohol withdrawal.2 Benzodiazepines remain the treatment of choice but they may need to be prescribed in lower doses and in some situations shorter acting drugs may be preferred.9 All older adults with AUD should have full routine health screens to identify physical and mental health problems. The evidence base for pharmacotherapy of AUD in older people is limited.42 Concurrent alcohol and substance use disorders Where alcohol and drug use disorders are comorbid, treat both conditions actively.2 Coexisting alcohol and benzodiazepine dependence This is best managed with one benzodiazepine, either chlordiazepoxide or diazepam. The starting dose should take into account the requirements for medically assisted alcohol withdrawal and the typical daily equivalent dose of the relevant benzodiazepine(s).2,43 In-­patient treatment should be carried out over a 2–3-­week period, possibly longer.2 Coexisting alcohol dependence and cocaine use In comorbid cocaine/alcohol dependence, naltrexone 150mg/day resulted in reduced cocaine and alcohol use in men but not in women.44 Topiramate seems ineffective.45 Coexisting alcohol and opioid dependence Both conditions should be treated and attention paid to the increased mortality of ­individuals withdrawing from both drugs.