Evidence-Based Reviews

Managing patients with comorbid opioid and alcohol use disorders

Current Psychiatry. 2023 February;22(2):20-28 | doi: 10.12788/cp.0327

Rachel Gluck, MD

Karen Hochman, MD

Yi-lang Tang, MD, PhD

Consider the type and severity of withdrawal symptoms, patients’ goals, and other factors.

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References

1. Mattson CL, Tanz LJ, Quinn K, et al. Trends and geographic patterns in drug and synthetic opioid overdose deaths - United States, 2013-2019. MMWR Morb Mortal Wkly Rep. 2021;70(6):202-207.

2. Hartzler B, Donovan DM, Huang Z. Comparison of opiate-primary treatment seekers with and without alcohol use disorder. J Subst Abuse Treat. 2010;39(2):114-123.

3. Nolan S, Klimas J, Wood E. Alcohol use in opioid agonist treatment. Addict Sci Clin Pract. 2016;11(1):17.

4. Hood LE, Leyrer-Hackson JM, Olive MF. Pharmacotherapeutic management of co-morbid alcohol and opioid use. Expert Opin Pharmacother. 2020;21(7):823-839.

5. Pikovsky M, Peacock A, Larney S, et al. Alcohol use disorder and associated physical health complications and treatment amongst individuals with and without opioid dependence: a case-control study. Drug Alcohol Depend. 2018;188:304-310.

6. Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug Alcohol Depend. 2019;197:78-82.

7. Hartzler B, Donovan DM, Huang Z. Comparison of opiate-primary treatment seekers with and without alcohol use disorder. J Subst Abuse Treat. 2010;39(2):114-123.

8. Jones CM, Paulozzi LJ, Mack KA; Centers for Disease Control and Prevention (CDC). Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths - United States, 2010. MMWR Morb Mortal Wkly Rep. 2014;63(40):881-885.

9. Stapleton RD, Comiskey CM. Alcohol usage and associated treatment outcomes for opiate users entering treatment in Ireland. Drug Alcohol Depend. 2010;107(1):56-61.

10. Turner RC, Lichstein PR, Peden JG Jr, et al. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med. 1989;4(5):432-444.

11. Boba A. Management of acute alcohol intoxication. Am J Emerg Med. 1999;17(4):431.

12. The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. J Addict Med. 2020;14(2S Suppl1):1-91.

13. Shaw JM, Kolesar GS, Sellers EM, et al. Development of optimal treatment tactics for alcohol withdrawal. I. Assessment and effectiveness of supportive care. J Clin Psychopharmacol. 1981;1(6):382-389.

14. Naranjo CA, Sellers EM. Clinical assessment and pharmacotherapy of the alcohol withdrawal syndrome. Recent Dev Alcohol. 1986;4:265-281.

15. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) national practice guideline for the use of medications in the treatment of addiction involving opioid use. J Addict Med. 2015;9(5):358-367.

16. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S Suppl 1):1-72.

17. Isenberg-Grzeda E, Kutner HE, Nicolson SE. Wernicke-Korsakoff-syndrome: under-recognized and under-treated. Psychosomatics. 2012;53(6):507-516.

18. Schuckit MA. Treatment of opioid-use disorders. N Engl J Med. 2016;375(4):357-368.

19. Tang Y-L, Hao W. Improving drug addiction treatment in China. Addiction. 2007;102(7):1057-1063.

20. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622.

21. Wines JD Jr, Saitz R, Horton NJ, et al. Overdose after detoxification: a prospective study. Drug Alcohol Depend. 2007;89(2-3):161-169.

22. Maughan BC, Becker EA. Drug-related mortality after discharge from treatment: a record-linkage study of substance abuse clients in Texas, 2006-2012. Drug Alcohol Depend. 2019;204:107473.

23. Gowing L, Ali R, White J. Buprenorphine for the management of opioid withdrawal. Cochrane Database Syst Rev. 2002;(2):CD002025.

24. Malinoff HL, Barkin RL, Wilson G. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. Am J Ther. 2005;12(5):379-384.

25. Nava F, Manzato E, Leonardi C, et al. Opioid maintenance therapy suppresses alcohol intake in heroin addicts with alcohol dependence: preliminary results of an open randomized study. Prog Neuropsychopharmacol Biol Psychiatry. 2008;32(8):1867-1872.

26. Srivastava A, Kahan M, Ross S. The effect of methadone maintenance treatment on alcohol consumption: a systematic review. J Subst Abuse Treat. 2008;34(2):215-223.

27. Davids E, Gastpar M. Buprenorphine in the treatment of opioid dependence. Eur Neuropsychopharmacol. 2004;14(3):209-216.

28. American Psychiatric Association. Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. American Psychiatric Association; 2018.

29. Hassanian-Moghaddam H, Afzali S, Pooya A. Withdrawal syndrome caused by naltrexone in opioid abusers. Hum Exp Toxicol. 2014;33(6):561-567.

30. Fairbanks J, Umbreit A, Kolla BP, et al. Evidence-based pharmacotherapies for alcohol use disorder: clinical pearls. Mayo Clin Proc. 2020;95(9):1964-1977.

31. Verrotti A, Scaparrotta A, Agostinelli S, et al. Topiramate-induced weight loss: a review. Epilepsy Res. 2011;95(3):189-199.

32. Flórez G, García-Portilla P, Alvarez S, et al. Using topiramate or naltrexone for the treatment of alcohol-dependent patients. Alcohol Clin Exp Res. 2008;32(7):1251-1259.

33. Jørgensen CH, Pedersen B, Tønnesen H. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcohol Clin Exp Res. 2011;35(10):1749-1758.

34. Mason BJ, Quello S, Shadan F. Gabapentin for the treatment of alcohol use disorder. Expert Opin Investig Drugs. 2018;27(1):113-124.

35. Sudakin D. Naltrexone: not just for opioids anymore. J Med Toxicol. 2016;12(1):71-75.

36. Rubio G, Jiménez-Arrieri MA, Ponce G, et al. Naltrexone versus acamprosate: one year follow-up of alcohol dependence treatment. Alcohol Alcohol. 2001;36(5):419-425.

37. Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet. 2018;391(10118):309-318.

38. Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014;8(3):153-163.

39. Dunne RB. Prescribing naloxone for opioid overdose intervention. Pain Manag. 2018;8(3):197-208.

When left untreated, opioid use disorder (OUD) is a debilitating and potentially lethal illness. Despite the availability of safe and effective medications for OUD, the prevalence of opioid use and overdose deaths has been increasing every year.¹ An additional challenge in OUD treatment is the high prevalence of comorbid alcohol use disorder (AUD).^2-6 A Clinical Trials Network survey from the National Institute on Drug Abuse found 38% of persons seeking treatment for OUD also had AUD.⁷ Other analyses have found alcohol was involved in approximately one-fifth of opioid-related deaths.⁸ Research also reveals that comorbid OUD and AUD contributes to poor treatment outcomes, more medical comorbidities, and a high risk of death (including overdose death).^4,9 There is no standard of care for this particular patient population.³ This article reviews the evidence and summarizes practical considerations regarding the clinical management of patients with comorbid OUD and AUD.

To illustrate the various decision points, we will follow 2 hypothetical patients through various stages of treatment (Figure), from their presentation in the emergency department (ED) or outpatient clinic, through their hospital admission (if needed), and into their outpatient follow-up treatment.

CASE REPORTS

Ms. A and Ms. B present to the ED for evaluation of nausea, vomiting, sweating, anxiety, and tremor. Both patients describe their most recent use of both alcohol and opioids approximately 12 hours ago, and each has been attempting to stop using both substances at home.

Decision-making in the emergency setting

In the ED, a few important decisions need to be made regarding treatment:

Are the presenting symptoms primarily due to alcohol withdrawal syndrome (AWS), opioid withdrawal syndrome (OWS), or both?
Does the patient require inpatient medical withdrawal management (detoxification) based on the history and severity of the withdrawal symptoms?
What are the patient’s treatment goals for their AUD and OUD?
Is maintenance medication for OUD indicated? If so, which medication is most appropriate?

In the ED, the presentation of individuals affected by both OUD and AUD can be challenging because OWS shares overlapping features with AWS, including nausea, vomiting, diarrhea, sweating, anxiety, and tremor. However, although acute OWS is typically very uncomfortable, it is rarely lethal. On the other hand, severe AWS may result in delirium, seizures, and death,¹⁰ which makes it essential to recognize and treat appropriately.

Both Ms. A and Ms. B should be medically evaluated and treated by an emergency medicine physician in conjunction with psychiatric (or addiction medicine) consultation. The ED assessment of a patient presenting with both AUD and OUD should include vital signs monitoring; physical examination; blood work including comprehensive metabolic panel, serum magnesium, and phosphorus; complete blood count; pregnancy test for women of reproductive age; urine drug screen (UDS); urinalysis; and serum ethanol level. Of note, sympathetic hyperactivity is found in both alcohol and opioid withdrawal, and patients with alcohol withdrawal may also have hypokalemia, a condition associated with an increased risk of arrhythmia. Furthermore, a prolonged QTc would affect clinical decision-making about medications for OUD (ie, methadone) and withdrawal management (ie, ondansetron, trazodone, and hydroxyzine). Therefore, an electrocardiogram should be conducted, where appropriate.

Initial treatment of AWS includes vitamin supplementation (thiamine, folic acid, and multivitamins) and benzodiazepine administration (symptom-triggered and/or scheduled taper). It may also include IV fluid resuscitation, analgesics for pain, ondansetron for nausea and vomiting, and other electrolyte repletion as indicated by the laboratory results.¹¹ Additional measures for patients in opioid withdrawal should include alpha-2 agonists such as clonidine or lofexidine for adrenergic symptoms, antiemetics, antidiarrheals, muscle relaxants, anxiolytics such as hydroxyzine, and sleep medications such as trazodone.¹²

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