In this episode of ASAM Practice Pearls, Dr. Stephen Taylor welcomes Dr. Itai Danovitch to discuss the descriptive term polysubstance use and methods for evaluating and managing patients with polysubstance intoxication and unknown toxidromes. The conversation covers strategies for assessing altered mental status, maintaining a broad differential diagnosis, safely managing agitation, and providing supportive care while avoiding common cognitive biases. This episode offers listeners practical insights for navigating clinical uncertainty and supporting patients from stabilization to treatment engagement.
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Host
Stephen M. Taylor, MD, MPH, DFAPA, DFASAM
Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states.
Expert
Itai Danovitch, MD, MBA, DFAPA, DFASAM
Dr. Itai Danovitch is Professor and Chair of the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center in Los Angeles. He earned his bachelor's degree from UC Berkeley and his medical doctorate from the UCLA School of Medicine. He completed a psychiatry residency at Columbia University, an addiction psychiatry fellowship at Cedars-Sinai Medical Center, and a Master of Business Administration at the UCLA Anderson School of Management. Dr. Danovitch’s clinical practice and research are focused on the treatment of substance use disorders and the integration of medical and mental health services. His research is funded by the National Center for Advancing Translational Sciences (NCATS), the National Institute on Drug Abuse (NIDA), and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). He is the author of over 100 articles and book chapters and co-editor of two books on substance use disorders. Dr. Danovitch served as a Governor-appointed state Commissioner to the California Mental Health Services Commission. He is a Distinguished Fellow of the American Society of Addiction Medicine, a Distinguished Fellow of the American Psychiatric Association, and past president of the California Society of Addiction Medicine.
📖 Show Segments
- 00:05 - Introduction
- 02:28 - Chapter 59 in The ASAM Principles of Addiction Medicine
- 03:45 - Patient Case: Altered Mental Status
- 06:01 - Polysubstance Use as a Descriptive Term
- 07:53 - Approaching Unclear or Mixed Toxidromes
- 11:36 - Completing a Differential Diagnosis Workup
- 14:54 - Responding When There Is a Lack of Clear Protocols
- 18:39 - Contaminants and the Changing Drug Supply
- 20:39 - Practice Pearls
- 23:33 - Lightning Round Q&A
- 27:35 - Conclusion and Additional Learning Opportunity
📋 Key Takeaways
- Conduct empirical evaluations and avoid confirmation bias: Polysubstance presentations often involve incomplete histories, unexpected substances, or contaminants. Remain comfortable with uncertainty, continually reassess the patient, and adapt management as new information emerges rather than becoming committed to an early diagnosis.
- Keep the differential diagnosis broad when evaluating altered mental status: Do not assume that all episodes of agitation, confusion, or delirium are caused solely by substance use. Consider intoxication, withdrawal, infection, trauma, metabolic disorders, neurologic conditions, and other medical causes.
- Supportive care is the foundation of managing most toxidromes: For many unknown or mixed toxidromes, treatment focuses on maintaining airway, breathing, circulation, temperature regulation, and patient safety while the body metabolizes and clears substances.
- Match agitation management to the underlying cause: Agitation related to withdrawal from central nervous system depressants may require benzodiazepines or barbiturates, while agitation or psychosis unrelated to withdrawal may be better managed with antipsychotic medications. Reassess frequently if symptoms fail to improve as expected.
- Create a calm, low-stimulation environment whenever possible: Reducing environmental stressors, providing reassurance, and avoiding the use of physical restraints (which can worsen agitation and lead to additional complications) can help improve outcomes and reduce complications in patients who are intoxicated or have an altered mental state.
- Toxicology screens are helpful but have limitations: Obtain toxicology testing early when appropriate, but do not rely on it exclusively. Some substances, such as GHB (gamma-hydroxybutyrate), may not be detected on routine screening tests, and negative results do not rule out exposure.
- Use local expertise to understand emerging drug trends: Emerging synthetic substances, contaminants, and adulterants can alter clinical presentations. Local surveillance data and poison control centers are valuable resources for understanding regional drug trends and obtaining management guidance.
- Treat agitation as a medical emergency rather than a behavioral inconvenience: Significant agitation may signal a serious underlying condition and requires prompt assessment, monitoring, and intervention.
- Engage patients with empathy and curiosity: Intoxication and altered mental status can be frightening and traumatic experiences. Use a supportive, patient-centered approach and learn from patients' experiences.
- Stabilization is only the beginning of care: Once a patient has recovered from intoxication or withdrawal, clinicians should engage them in conversations about substance use, provide harm reduction education, assess for substance use disorders, and connect them with evidence-based treatment when appropriate.
🔗 Resources
- The ASAM Principles of Addiction Medicine 7th Edition - Miller SC, Rosenthal RN, Levy S, Saxon AJ, Tetrault JM, Wakeman SE, eds. Wolters Kluwer; 2024.
- Chapter 59: Management of Stimulant, Hallucinogen, Cannabis, Phencyclidine, and Other Drug Intoxication and Withdrawal - Wilkins JN, Gorelick DA, Danovitch I, Athanasiou N, Allen S.
- Implementation Guide for Hospital and Emergency Department Substance Use Disorder Care
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In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
