Managing Co-Occurring Alcohol and Poly Substance Use

It is common for people to use more than one substance when using drugs, including alcohol. In pregnancy, this can complicate pregnancy, birth, and infant outcomes compared to people only using one substance. As well, there are higher risks of drug poisonings and other harms in certain marginalized populations, such as those experiencing poverty and Indigenous people, and these harms are heightened in pregnant people. Pregnant individuals who use multiple substances typically are not engaged in care, including prenatal care. This is due to the complex, intersecting social conditions related to stigma, judgment, fear of child apprehension, and lack of safety in healthcare environments.

Approach

For clinicians working with these clients, using non-judgmental and safe approaches to engaging clients in care and retaining them is extremely important. At an early stage, providers should ask about alcohol use in a non-judgmental way, being mindful to use person-first and non-stigmatizing language. Seeking consent prior to asking screening questions can foster trust and comfort.

Example:

“I discuss the effects that alcohol have on health and pregnancy with all my patients. Would it be ok to talk about this?”

If the client consents, asking open-ended questions is a respectful way to continue. Example:

“How does alcohol fit into your life?”

Clinicians can gauge the client’s comfort and interest in learning more and then decide whether to continue the discussion and conduct a screening test (e.g., AUDIT-C, T-ACE, TWEAK).

More information: Screening and treatment pathway for pregnancy; and guidance for starting the conversation

Individuals who disclose alcohol use should be screened for co-occurring substance use using validated tools such as the ASSIST and TAPS. To continue building trust and safety, providers should discuss treatment options in a collaborative way, be respectful of the client’s agency and choices, and take additional steps to reduce the power imbalance inherent in the healthcare system. At all stages of care, foundational principles of patient-centred, culturally safe, trauma-informed and strengths-based care should be applied and practiced with clients. Refer to the Principles of Care for more details. Connecting clients with services in the community is also important to support their other health and social needs.

Given the greater risks to the patient, providers need to exercise greater caution in their planning and may need to engage further support to ensure the safety of the patient and the fetus, particularly around withdrawal management or treatments for polysubstance use. Further, these clients will likely need additional supports upon discharge that are contextualized to their circumstances and needs. General considerations are presented below, followed by specific guidance for common co-occurring substances.

General Considerations for Withdrawal Management from Multiple Substances

Assessment of withdrawal symptoms from multiple substances during pregnancy can be complex:

Various substances can lead to the same withdrawal symptom (e.g., withdrawal from opioids or alcohol can lead to tremor). Simultaneous withdrawal could also potentiate the symptom severity. This can lead to inaccurate results on a symptom assessment scale for a single substance, like the CIWA for alcohol.
Certain withdrawal symptoms are common features of pregnancy, such as nausea or vomiting. Teasing apart the cause of these symptoms can be difficult and requires accurately tracking the timelines of symptom onset, pregnancy stage, and substance use reduction.

It may be difficult to identify which substances were being used:

Due to drug supply contamination, patients may not be aware of the substances they are using. For example, they may report fentanyl use, but are unaware of additional components (such as benzodiazepines) present in their substance.
Substance contamination may complicate the withdrawal process, causing unexpected or more severe symptoms.

Due to these complexities, inpatient treatment is recommended to allow for close monitoring and frequent assessment of symptoms. If possible, a clinician experienced in withdrawal during pregnancy can be involved in the symptom assessment and medication dosing strategies. Simultaneous substance withdrawal is preferred if feasible, with severity of symptoms guiding the treatment decisions while also noting that withdrawal is not always a necessary step for initiating long-term treatment (e.g. opioid agonist treatment). When not feasible, the substance withdrawal that poses the greatest potential harm to the patient and fetus should be prioritized and managed first.

Guidance for Withdrawal Management or Treatment of Co-occurring Alcohol and Other Substances

Tobacco and Alcohol

Smoking cessation during pregnancy is more difficult for people who use multiple substances, including alcohol, compared with those who use only tobacco.
Pharmacological tobacco cessation interventions (bupropion or varenicline) are safe to implement at the same time as treatment for alcohol (naltrexone or acamprosate) in the general population. Varenicline and naltrexone has been shown to be an effective combination.
Due to the lack of evidence of safety and efficacy data of combined treatments in pregnancy, risk and benefits of medications should be weighed and discussed with the patient and only prescribed in close consultation with a perinatal addiction medicine specialist. Informed and ongoing consent and shared decision-making with the patient are essential.

Opioids and Alcohol

Co-occurring use of opioids and alcohol is associated with an increased risk of respiratory depression, overdose, and death.
Acute opioid withdrawal should be avoided during pregnancy as it increases the risk of relapse or overdose and may cause severe adverse fetal outcomes. Assess for history of overdose and risk of relapse if patient chooses to withdraw from opioids.
Initiation of opioid agonist treatment (OAT) is recommended as soon as possible.
- The type of OAT should be selected based on individual circumstances and with consideration of access and availability.
- Buprenorphine/naloxone is the preferred OAT medication due to its better safety profile.
- Methadone and slow-release oral morphine should be prescribed with caution and involve close follow-up, as there is a risk of respiratory depression and drug toxicity when combined with alcohol.
  - Take caution with prescribing benzodiazepines alongside methadone, due to increased risk of respiratory depression.
- Injectable opioid agonist treatment (iOAT) has not been studied in pregnancy but can be offered for severe cases at the clinician’s discretion.
Do not prescribe naltrexone for AUD in those who currently use opioids, as naltrexone can cause opioid withdrawal. Naltrexone will also reduce efficacy of systemic opioids for pain in labour. Consider acamprosate for ongoing AUD treatment.
- Managing Co-occurring Opioid and Alcohol Use Disorders handout provides more information.

Stimulants and Alcohol

Patients with co-occurring alcohol and stimulant use are at increased risk of severe and protracted withdrawal, anorexia, insomnia, and agitation.
Higher doses of benzodiazepines may be needed to manage withdrawal from alcohol and stimulants. For details on benzodiazepine use and standard dosing in pregnancy, see the Medication Table.

Benzodiazepines and Alcohol

Combining benzodiazepines and alcohol increases the risk of respiratory depression.
Onset of alcohol withdrawal symptoms may be masked or delayed when benzodiazepines are present, which can increase the severity of withdrawal symptoms, including seizures.
Patients with co-occurring benzodiazepine use disorder may require higher doses of benzodiazepines to manage alcohol withdrawal symptoms.
A gradual and stepped dose reduction or taper should be initiated for individuals who have been using benzodiazepines for more than 4 weeks (whether prescribed or non-medical use) or those who meet criteria for a sedative use disorder.
For severe alcohol withdrawal, a fixed-dose or symptom-triggered schedule of benzodiazepines for 5-7 days is recommended to manage symptoms. Doses should be tapered off until symptoms have resolved. For details on benzodiazepine use and standard dosing in pregnancy, see the Medication Table. However, for patients with co-occurring benzodiazepine use, the dosing schedule may need to be longer (i.e., a slower taper) to account for the delay in symptom onset. A longer, slower taper is compatible with the course of treatment for benzodiazepine use as well.