Polydrug addiction

Polydrug addiction (polydependence) is a disease associated with the use of two or more drugs simultaneously or in a certain sequence, with dependence on all of them formed.

ICD-10 code

E19 Mental and behavioral disorders caused by the simultaneous use of several drugs and the use of other psychoactive substances.

The combined use of various psychoactive substances changes the clinical picture of the disease, affects the rate of formation of the main symptoms and syndromes, and leads to more severe medical and social consequences.

Most often, the first psychoactive substances tried are alcohol and cannabis preparations. It has been established that most people with opioid dependence, before starting to use them, usually took the said substances episodically or, much less often, systematically. Sometimes drug addicts use several psychoactive substances for a long time from the very beginning, in such cases it is not possible to identify a "preferred" drug (even by the time of the formation of AS), only the desire to change one's condition and to obtain any euphoria, and not some specific to a certain substance, is noticeable. With random use of different drugs, the nature of the euphoria depends on the main drug.

The time of formation of AS in polydrug addiction depends on the combination of substances taken, their single and daily doses, and the method of administration. In general, the described patients demonstrate a relatively rapid development of the dependence syndrome. In particular, the most rapid formation of all signs of the disease is noted in cases where the main substances are opioids. In the shortest time, the formation of AS occurs in patients with heroin-cocaine, heroin-amphetamine polydependency, which indicates a rapid progression of these forms of the disease.

Unlike mono-drug addicts, who seek to relieve withdrawal symptoms only by taking their usual substance and use others only in its absence, poly-addicts use any means available to them from the very beginning to alleviate their condition. Alcohol is often used for this purpose.

The clinical manifestations of withdrawal syndrome in polydependency are varied (especially in cases of initial intake of different drugs). However, if the main substance is an opioid, then the clinical picture of the withdrawal state is mainly determined by it, and other intoxicating drugs change only individual features.

The most common combinations of narcotic and intoxicating substances are:

• alcohol with sedatives, less often with marijuana and cocaine;
• opioids with marijuana, cocaine and amphetamines, with alcohol.

Combined use of alcohol and sedatives

Most often, tranquilizers, mainly benzodiazepines, are used with alcohol. There is a large group of people who combine drinking alcoholic beverages with taking composite drugs containing barbiturates or antihistamines, which have a pronounced sedative effect.

Clinical manifestations of chronic alcoholism with combined use of ethanol and sedative-hypnotic drugs have a number of features. The main motives for the initial use of sedatives are the removal of alcohol intoxication, relief of withdrawal symptoms and normalization of sleep, and in adolescents, the desire to change the mental state.

The transition from alcohol abuse to psychoactive substance use occurs both during periods of remission of chronic alcoholism and against the background of prolonged alcohol use. A characteristic feature of the clinical manifestations of alcoholism in most such patients is a constant type of primary pathological attraction to change their mental state, realized in several ways.

The initial use of psychoactive substances to achieve euphoria is one of the most common options. The change in the nature of alcohol intoxication, when alcohol loses its euphoric and activating effect and causes pronounced dysphoric disorders, aggressiveness, leads to the fact that patients with chronic alcoholism gradually increase the doses of alcohol consumed to revive positive experiences. However, taking large amounts of alcohol only increases affective and psychopathic symptoms and does not eliminate the emerging desire for intoxication. To achieve the desired effect, patients begin to use various sedatives and sleeping pills.

Taking psychoactive substances for therapeutic purposes during the period of remission of chronic alcoholism is another common cause of their abuse. Alcoholics take tranquilizers, barbiturates and other sedatives as prescribed by a doctor to eliminate somatovegetative disorders. Attacks of increased craving for alcohol can occur in the form of "outbursts" of dysphoria, increased irritability, anxiety, restlessness, and a feeling of unmotivated fear. The prescribed drugs provide a positive effect for some time, but the gradual development of resistance to them requires an increase in single doses by 2-3 times. However, drugs in such quantities have an intoxicating effect on alcoholics, which can lead to the formation of addiction.

Taking edematous-hypnotics with a substitution purpose to alleviate the manifestations of alcohol withdrawal syndrome can also serve as a reason for their abuse. Due to the increased resistance of patients to sleeping pills, tranquilizers and other sedatives, therapeutic doses are not always effective, which requires exceeding them. Having a pronounced anxiolytic effect, these substances eliminate anxiety, stress, tension, and guilt. Due to the hypnotic and anticonvulsant effect, insomnia passes, the development of epileptiform seizures is prevented. Correction of somatovegetative functions occurs: pain in the heart area, tremor disappear, hyperhidrosis decreases, the feeling of fatigue and lethargy is relieved. However, the duration of action of the drugs rarely exceeds 2-3 hours, after which withdrawal disorders occur again, forcing patients to take them again. It should be noted that in severe withdrawal states, the use of drugs in doses exceeding therapeutic doses by 2-3 times does not cause positive experiences. However, the milder the manifestations of withdrawal syndrome, the stronger the euphoria. Such a feature serves as a basis for continued drug abuse and the formation of addiction.

Substitute (vicarious) episodic use of sleeping pills, tranquilizers and sedatives in doses exceeding therapeutic ones to achieve euphoria does not cause dependence on them.

The time of formation of dependence on sedative-hypnotic drugs in patients with alcoholism is significantly reduced and on average is 2-3 weeks 3-4 months. Its formation is significantly influenced by premorbid personality traits, the severity of the primary pathological craving for alcohol, drug-producing properties, dose and nature of psychoactive substance intake.

Combined use of ethanol and sedatives aggravates the course of chronic alcoholism. First of all, an increase in tolerance to alcohol and aggravation of amnesia are noted. Continued abuse leads to a deepening and prolongation of binges, a gradual approach of drunkenness to permanent. An aggravation of alcoholic AS is noted - the prevalence of psychopathological disorders, which is manifested by emotional disturbances with a melancholy-angry mood, aggressiveness, anxiety, restlessness. Significant sleep disturbance is characteristic: patients cannot fall asleep for a long time; sleep is shortened to 2-3 hours, superficial, restless, with unpleasant, often nightmarish dreams. The frequency of suicide attempts, epileptiform seizures, acute psychotic disorders increases. The duration of the abstinence state is 2-3 weeks.

When switching from alcohol abuse to sedative-hypnotic drugs, a gradual transformation of abstinence from alcohol to a withdrawal syndrome of sleeping pills and tranquilizers is noted. In general, the course of addiction to other psychoactive substances against the background of chronic alcoholism is characterized by malignancy, rapid progression, early appearance of somatic, neurological, mental complications.

Medical and social consequences also occur very quickly. Persistent psychopathological disorders are characteristic: affective disorders in the form of dysphoria, with daily mood swings, often with suicidal behavior. At the same time, there is a deepening of intellectual and mnestic disorders: a sharp decrease in memory, intelligence, attention, slowing and difficulty of thought processes, impoverishment of vocabulary, mental exhaustion. A radical change in personality occurs, patients become egocentric, deceitful, embittered, lose generally accepted moral and ethical standards. Organic dementia and complete social and labor maladjustment develop, which leads to disability.

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Combined use of opioids and alcohol

The coexistence of alcoholism and drug addiction is quite common in clinical practice. Early age of onset of alcohol abuse is an unfavorable prognostic sign and a risk factor for the development of drug addiction in the future. Often, the first opioid tests in the case of established alcohol addiction occur to alleviate a hangover. However, the opposite is possible: alcohol addiction is a frequent consequence of opioid addiction, since patients begin to abuse alcohol in order to overcome withdrawal disorders, as well as in remission.

Alcohol consumption in patients with opioid dependence often leads to altered forms of intoxication with dysphoria and aggression. The most massive alcohol consumption is observed during opiate abstinence and in the post-abstinence period. The craving for alcohol at this stage is usually caused by the desire of patients to alleviate their physical and mental condition. The development of alcoholism against the background of opioid dependence is rapidly progressive, often lightning fast. The first signs of alcohol withdrawal syndrome are noted within a few weeks, less often - months, after the onset of abuse. Its abnormal course is characteristic: the prevalence of pain and vegetative disorders typical of opioid withdrawal syndrome is possible. Moreover, their subjective severity often serves as a reason for the resumption of drug use. The combined use of opioids and alcohol significantly worsens the somatic condition of patients and indicates an unfavorable prognosis for the disease.

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Combined use of opioids and psychostimulants (amphetamines, cocaine)

The use of opioids together with psychostimulants, in particular with amphetamines, is one of the most common variants of polydrug addiction. Patients with opioid addiction most often use amphetamines either in search of new sensations (wanting to compare the effects of drugs with each other) or in order to alleviate the course of opiate withdrawal.

The combined use of opioids and psychostimulants significantly changes the euphoria and clinical picture of intoxication. Amphetamines and cocaine reduce the dose of opioids required to achieve the effect. As a rule, combined drug use is preceded by stages of using one of the substances and developing dependence on it. Most often, such a substance is a drug of the opium group.

The clinical picture of mixed intoxication with intravenous administration of opioids and amphetamines consists of two alternating phases.

1. The first phase (the so-called rush) is sharply intensified, longer lasting than the effect of each drug separately, its duration is on average 4-10 minutes.
2. The second phase (intoxication). Characterized by an elevated mood with good nature, pleasant relaxation and languor, a feeling of complete peace and indifference to everything, bliss, i.e. a feeling typical of opium intoxication, but with mixed intoxication, patients additionally experience a surge of strength, a feeling of activity, their own omnipotence. They are excited (including sexually), strive for activity, for communication with each other, feel an extraordinary clarity and distinctness of thoughts, and simultaneously with a feeling of lightness and flight, they feel a pleasant heaviness of their own body.

The characteristic euphoria often serves as an incentive for continuing the continuous use of drugs for several days. During this period, there is a rapid development of psychological dependence on the new substance, an increase in single and daily doses, and an increase in the frequency of administration. Continuous use of psychostimulants can lead to exhaustion of patients, which causes a short-term decrease in tolerance to opioids. However, with their further use, tolerance again rapidly increases and reaches its original values. One of the characteristic features of the action of amphetamines is the ability to alleviate the course of opiate withdrawal syndrome. Moreover, there is a complete elimination of pain, general weakness, a feeling of exhaustion, patients feel an uplift in mood, a surge of strength, and vigor. Preservation of some symptoms of opiate withdrawal is noted, primarily pronounced mydriasis, sleep disturbances, motor restlessness, and individual vegetative disorders. Amphetamines also reduce suspiciousness and hypochondria, characteristic of patients with opioid dependence during their withdrawal. The craving for opioids is not suppressed, but at the height of intoxication with psychostimulants it loses its relevance.

Gradually, patients begin to take drugs, randomly alternating or in combination, it is impossible to isolate the predominant substance. Moreover, the craving for opioids remains, especially increasing in the case of their availability or in the absence of psychostimulants.

In case of discontinuation of combined use of narcotic substances, 12 hours after the last intake, the development of abstinence syndrome is noted. Its manifestations are very diverse, and the severity of certain symptoms depends on which of the two drugs the patient has preferred recently. If opioids were predominant, then pain and autonomic disorders prevail in the structure of the abstinence syndrome, but if psychostimulants were predominantly used, asthenodepressive disorders. Patients note a deterioration in mood, they become lethargic, apathetic, an unstable emotional background with frequent, quickly depleting outbursts of irritability, rapid depletion of mental processes, slow thinking, drowsiness are characteristic. After 1-2 days, drowsiness gradually gives way to insomnia: patients cannot fall asleep without sleeping pills; sleep is superficial, with frequent awakenings; dreams are nightmarish or narcotic in nature. Early awakening and lack of a feeling of rest after sleep are typical, as well as a perversion of the sleep-wake rhythm (patients are sleepy during the day and cannot fall asleep at night). A gradual increase in irritability and dysphoria is noted, unmotivated anxiety, internal tension, and increased sensitivity to external stimuli may occur. Appetite does not suffer. The use of psychostimulants significantly increases the likelihood of developing delusional disorders (they are practically not encountered with isolated opiate AS).

After acute withdrawal disorders have passed, affective disorders are revealed for a long time - a depressed mood, emotional instability, weak-willed reactions, rapid exhaustion of mental processes, poor concentration, craving for drugs. In general, combined abuse of opioids and psychostimulants worsens the course of drug addiction: the number of severe somatoneurological complications increases. Personality changes occur quickly.

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Combined use of opioids and tranquilizers

Drugs and tranquilizers are most often used in combination by patients with an already formed addiction to opioids. The reason for this is the development of resistance to the drug and the loss of its euphoric effect. The addition of tranquilizers allows patients to reduce the dose of opioids that causes euphoria. Thus, for some time, the effect of stopping the growth of resistance to the drug is observed. With the combined use of opioids and tranquilizers, the picture of intoxication changes:

• the first phase of euphoria (“rush”) becomes “softer” and longer lasting;
• The second phase (intoxication) observes a decrease in the stimulating effect, characteristic of the formed dependence on opioids.

Later, as tranquilizer dependence develops, patients lose the ability to experience the pleasure of opioids alone (even when using very large doses), and individual symptoms of sedative withdrawal occur against the background of opium intoxication. The overwhelming majority of patients in the state of AS are characterized by a gloomy-depressed mood with irritability, a tendency to dysphoric reactions and hyperacusis. Many patients complain of anxiety, internal restlessness. A significant proportion of patients experience motor restlessness in the state of withdrawal. Often, patients, along with irritability and anxiety, note indifference to everything, lack of desires, motivations, and interests. Psychopathological disorders during drug withdrawal are accompanied by severe sleep disorders (they are observed in almost all patients, in some of them they reach the level of insomnia). The combined use of tranquilizers and opioids significantly increases the risk of drug overdose, which may require emergency medical care.

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