# 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.