Hey everybody, welcome back to my channel. It’s Dr. B and today’s topic is going to be polysubstance abuse. Really important topic. I’ve touched on it before. It’s critical and the information here should be useful for the user, for the loved ones, also for those at treatment facilities and systems and institutions that deal with substance abuse and how to approach it. Let’s get started. Polysubstance abuse. Let me break something down to kind of give you an idea what a mess, what a horror show we have today,

 

okay? If you went back 30, 40, 50 years, okay, and let’s take two classes of drugs, drugs of abuse. Stimulants, you know, whatever you wanted to call it, crank, speed, amphetamines, whatever it was, versus opiates, which was traditionally heroin. When you go back 30, 40, 50 years, back in the day, these were very two different subcultures. In some senses, you could say the white biker gangs were into the methamphetamine scene, the crank scene, the speed scene, whatever it was called. And the opiate kind of subculture was a whole different set of people, okay?

 

They never mixed, and the drugs never mixed, and you stuck to your drug. Come up 50 years, 40 years, 30 years, 60 years, whatever it is. Today’s user, addict, the person presenting for treatment, everything is in their system and they are using everything. And in fact, this is critical to understand, not only for the user seeking treatment and why they need to stop this sort of behavior and how it’s impacting their health and their

 

treatment course, but also providers and systems that are providing. Let’s just start from the addict’s perspective. It’s not that you’re just using a stimulant and an opiate or a sedative hypnotic like a benzodiazepine. The issue here is the stuff that’s being sold on the street nowadays is just cut up garbage with everything you can imagine in it. Okay. So number one, you know, you’re introducing a lot of foreign elements into your system that you don’t know what effect they’re

 

going to have. Even if you were trying to get a methamphetamine and then get your hair on, those are all cut up in such a nasty way. This can have profound effects, okay? It could have a synergistic effect, right? It could contribute to overdoses, and it could also contribute, or sort of like overdoses. Let me give you a couple of examples, okay? You know, if you’re mixing opiates and benzodiazepines, you are increasing your likelihood of an overdose, okay? If you’re adding alcohol to cocaine, you know, that cocaine,

 

okay, is a lot more toxic and a lot more potent in your system than if you were just taking alcohol and cocaine. And so any event that’s going to happen, you should think of it as a greater likelihood of it happening. For example, a stroke, myocardial infarction, which is a heart attack, a brain bleed. In addition, I’m talking if you were getting the pure substances, okay? But these things are cut up and that adds another layer of complexity and danger to your health

 

and to your systems. That’s from the user side. Now, let’s go to the side of the provider. We’ve spent, what is it now, 20 years in the opiate epidemic? It started out with big pharma, and it’s a doctor’s falls and prescription medication. Opiates turned into heroin use. And we’re not making any movement in a real sense for me. And the movement that we are making is not enough. And maybe we’re just kind of catching up on opiates. Maybe we’re just catching up slightly on methamphetamine.

 

Okay. This guy’s a methamphetamine user, but the guys presenting to the doctor’s office, to the treatment centers, to detoxes, rehabs, they have polysubstances. Not only are the providers not equipped to understand how to approach this kind of issue, the system itself. Now, if you go to a pay for service system, a fee for service that people use with insurances and going to detoxes, the idea is, oh, you’re on benzodiazepines,

 

you are methamphetamine, and you’re on opiates. Okay, I’m going to try and get it approved for five days, and we’ll call this detox. And let’s rip you off of all of these. Okay, then you go down to the next level in the ladder. It doesn’t work for the most part, okay? People have a high rate of relapse and come out worse sometimes than they started. So if you’re going down that route of polysubstance abuse, understand that the system can’t even

 

process you appropriately. A, at the provider level, if we’re talking about the medical doctors, you know, I’m not sure if everybody’s on the same page and understands how you should approach this situation. B, if you’re going using your insurance and going into detoxes and rehabs, the way the payments are set up do not provide for a safe, sane, thoughtful approach that is algorithmic in getting you off these substances in the long run and making sure you stay off of it.

 

So let’s talk a little bit about the way this should be done. Let’s say, and I’ve used this example before or something like it, and hopefully this provides a little bit of thought, not only for the user and how it should be done so when they confront that treatment system, whatever system you’re approaching, and you know, hey, this is wrong, they shouldn’t be doing this, whether you’re approaching the treatment system, or if you are a provider, whether you’re in a detox facility, whether you

 

are in a mental health facility, or whether you’re just a medical doctor trying to get this guy clean, this should help all parties, all sides to approach this in a safe, sane, thoughtful, and humane way. Because not only is any other way potentially dangerous, i.e. ripping someone off of benzodiazepines, but it’s also mean and cruel and unusual. Depending on where your addiction is,

 

ripping you off on some of this stuff is not only dangerous, but extremely painful. But also hopefully where you get a sense that some of these things need to be approached in a risk benefit approach and thought and continued for the long run, which the traditional detox at this point can’t really do. Okay, you get a guy that’s approaching you and they have a heavy opiate use, okay, and let’s just make it that it’s intravenous and they smoke it.

 

The opiate is fentanyl. Now, in fact, let’s make it even more complicated. We can’t really test this right now, but there are some hints of nitrosines in there. Okay. And also they have an amphetamine abuse. Okay. Whether they’re smoking it or intravenous, who knows? And they’re using that three, four or five days a week and they minimize it as they often do. Oh, I only do that to come to get back going after I use opiates. Oh, I only use that once a week. Dangerous play that you’re doing. And then there’s

 

also benzos. You find out, hey, how much benzos are you using and what are you using? Oh, I get Xanax. Where do you get it? I buy it off the street. Are they pressed? I don’t know. And then all of a sudden, you’re in toxicology, MDMA and other things show up. Okay, this is a complicated, complex patient. What you have to look at here, if you were the treatment provider to approach this, and this is good for you to know as well, if you’re the user, loved one, family. Opiates, it’s the easiest one to approach, and

 

it’s the first thing that should be in everybody’s algorithm. I have medication to transfer from opiates that they’re buying off the streets, whether it’s pills, whether it’s heroin, whether it’s fentanyl, whether it’s nitrosines diluted and all of that, you need to immediately replace that, not think about anything else, but you need to immediately get them off of the opiates and get them on medication-assisted treatment, buprenorphine products, Suboxone, whatever it is.

 

That needs to be stabilized first. Why? We have a medication for it. And no matter how you look at it, regardless of what the critics are saying out there or watching here and have some negative thing to say about me and know that drug companies don’t have me in their back pocket. I could make a lot more money selling marijuana products or cradle. You need to get on medication-assisted treatment, buprenorphine, and the treatment provider in my view, right? That’s why I don’t own a detox

 

anymore. I don’t own an intensive outpatient treatment anymore. I did run a methadone clinic, but I don’t deal with anyone. It’s my medical practice. So when you come in and you’re using methamphetamines and you’re also using benzos, I’m going to tell you, you got to get off those benzos because they’re dangerous, but let me do this in the next couple of days. And I immediately get you on medication-assisted treatment. Once that’s stabilized, now I start to get a much more clear picture

 

of where your methamphetamine use is and where your benzodiazepine use is. I also get a much clearer picture of your comorbid, that means your other mental health issues that may have been contributing to your original substance abuse or the substance abuse making those worse or those arising out of your substance abuse. Psychosis, anxiety, panic attacks, depression. I have no comments on any of these until I get some of these substances off board or

 

under my control to deal with those. Getting you on medication-assisted treatment after that, I will see to what extent that clarifies my view of your insomnia, of your anxiety, of your depression, of your panic attacks. Now, some of you might say, why? How? Well, here’s how and here’s why. Number one, the opiates may be contributing to any one of those for multiple different reasons, masking some of those or

 

treating some of those. Now I have you on medication-assisted treatment, so I kind of get an idea where those stand. Now I compare all of that and take a look at all of that and reflect it on your methamphetamine use, however it is, your stimulant use, and then your benzodiazepine use. I mean, does this guy have just a severe anxiety and panic attacks that he needs to be? He’s self-medicating with these. The next thing I do of those three, again, what can I do with what?

 

And what is the most dangerous thing, right? Well, the opiates is a double whammy. One, I have a medication. Two, two, you can overdose. Now I moved to the benzos. Why? If you’re buying stuff off the street and this stuff is cut up or the pills are pressed, you can overdose anytime on those. Two, I don’t want junk going into your body without me knowing what’s in it. You’re going to tell me, oh, I take three or four Xanax, two milligram bars.

 

Oh, every few days. I’m going to assume you’re taking 10 milligrams of Xanax a day. That’s how it usually goes. Now, this is also a little bit tricky now that I have you somewhat stabilized. I will transition you on a benzodiazepine of my choice enough where I deal with cravings, withdrawals, withdrawals, first physiological withdrawals that can kill you or hurt you really bad by giving you a seizure, then as much cravings as I can muster up in a safe margin,

 

and then I’ll discuss with you regarding your psychological cravings if there are any left. And this has varying degrees of difficulty depending on the patient, their age, underlying anxiety group of disorders, and their desire and propensity at this time to get clean. Okay. But sometimes it’s a little work. Sometimes it takes a couple of days. Sometimes it takes a couple of weeks. Sometimes you have to go from clonopin to volume, et cetera, et cetera. But I

 

need to get that under control. I got to get that under control. You can’t be buying stuff on the street. I need to know what’s going in your body and how much. There’s quite a bit of nuance to that. And we really try to hit each issue. And most importantly, you have to have the patient on board. You have to give them some sort of comfort, empathy, sympathy, nonjudgmental, and dissipate their fear. If they already have anxiety and panic issues, you can make this worse and they’ll run and it’s bad news. You have to negotiate it

 

from a provider side in some ways and not be judgmental. This could be three or four days into our treatment. This could be a couple of weeks into our treatment. But if I’ve already got you on Suboxone, I’m not going to kick you out because you keep coming and telling me you’re doing benzos and meth, right? That would be crazy. I would kick you out. You would go back to illicit opiate use and make the problems worse. It’s a chronic disease. You can’t try to win days from the insurance company. And you take quite a bit of loss for those of you that think there’s so much money in this. You take quite a bit of loss. For those of you that think there’s so much money in this,

 

you take quite a bit of loss if you’re doing this correctly. Now that I got you on the appropriate dose of benzos, you’re with it some more. I have you cognitively inclined into me. Your concerns, fears, lack of trust hopefully should be dissipating. I should be on the side of all this. I should be building a rapport with you. I should be creating a situation where your judgment, your fears, your anxiety about my practice starts to go away and you start to feel safe when you come to see us.

 

Okay, now let’s take a look at your methamphetamine use. Now let’s take a look at your sleep. Now let’s take a look at your diet, your water intake, your comorbid psychiatric, psychological issues, personality disorders, anxiety disorders, depression, bipolar, schizophrenia. Let’s look at those. Let’s see what you’re on. Let’s see if we can clean those. Let’s see what you’re on. Let’s see if we can clean those. And now we can, since we’ve really put out quite a lot of the fire, oftentimes the provider should see that the person’s

 

methamphetamine use will start to decrease. They themselves become self-aware of their behavioral patterns because you’ve given them a lot of cognition back. They’re quite a bit plugged into the world again. Okay. And this might take a few weeks. This might take a couple of weeks. This might take a year, but you can get there and you don’t have any other choice as a provider has to be nonjudgmental. They have to be honest with you. And meanwhile,

 

you can start working on other medications that assist if need be for sleep. Be careful if you’re the provider of labeling diagnoses until they’re completely off of all medications. And there you have it. Guys, if you like what you’re hearing on here, or even if you don’t, but you find it stimulating, think about subscribing. Think about Patreon. Think about a small monthly contribution. We are trying to get this channel to the next level.