Is It Possible to Withdraw From both Alcohol and Opiates at the Same Time?

Medicine in the Future.

I recently participated in a Webinar entitled “Managing Alcohol Withdrawal in the Correctional Setting.” During the question and answer section of the Webinar, a question was posed about how to manage the patient withdrawing from both alcohol and heroin at the same time.  I have been thinking about this question since.  In all my years of practice in correctional settings, I personally have never seen a patient who was simultaneously withdrawing from both alcohol and narcotics.  Is such a thing even possible?

After thinking about it, I have decided that this question this question has two answers:  a theoretical answer and a practical answer.  The theoretical answer first:

Theoretically, if a patient was truly suffering from both alcohol withdrawal and heroin withdrawal at the same time, our primary concern would be alcohol withdrawal rather than heroin withdrawal.  The reason for this is that patients die from alcohol withdrawal; it is a potentially lethal problem.  Heroin withdrawal, on the other hand, can be a serious medical problem, but does not tend to be lethal.  I was an emergency physician before I came to corrections, and this principle was drilled into us over and over–you deal with the life threatening concern first.

It would be theoretically possible to treat both at the same time–give Valium, say for alcohol withdrawal and clonodine for heroin withdrawal, but you would have to be careful of the potential drug interactions between these two medications.  Perhaps I would treat the alcohol withdrawal like I usually do with symptom driven Valium but not use as  much clonodine as I normally would for heroin withdrawal.

But, again, all of this is theoretical because though I have treated literally hundreds of patients for alcohol withdrawal and hundreds more for narcotic withdrawal, I personally have never seen a patient who withdrew from both at the same time.

This brings us to the practical answer to the question.  The practical answer is that, as a very strong general rule, patients do not withdraw from both alcohol and heroin at the same time.  It takes many years of dedicated daily heavy drinking to cause the brain receptor changes that result in alcohol withdrawal.  That is why most alcohol withdrawal patients we see are middle-aged.  Young people usually have not been at the business of dedicated drinking long enough to lead to withdrawal (there are exceptions to this, but as a general rule, the younger the patient, the less likely they are to go through alcohol withdrawal, even if they are a heavy drinker).  Heroin addicts are more interested in heroin than alcohol.  They may drink, but not enough to lead to true alcohol withdrawal.

However, it is not uncommon for heroin addicts to say that they are going to withdraw from alcohol as well as heroin.  Especially if they have been through the system before, they know that alcohol withdrawal is treated with a benzodiazepine like Valium.  What they are doing is trying to score a little Valium.  I usually view such claims with suspicion.

So if a patient presents in the jail and says that he is going to withdraw from alcohol as well as heroin, I usually will treat him according to our narcotic withdrawal protocol.  We will also do an alcohol withdrawal score, but it is unlikely that he will get any Valium.

Any thoughts? Has anyone seen simultaneous withdrawal from alcohol and narcotics?