Polysubstance use is the norm rather than exception in treatment of substance use disorders (SUD). The majority of individuals entering treatment report using more than one substance, and many experience cravings for multiple substances simultaneously. In certain treatment settings, 60–80% of patients use multiple substances, underscoring the complexity clinicians face from the moment care begins[1][2][3]. This complexity has real consequences. People using multiple substances tend to have poorer treatment retention, higher relapse rates, and higher mortality compared to those using only one[4].
Why it matters
Despite this reality, most clinical trials for SUD focus on single-substance users, which doesn’t reflect the real world[5]. This makes it harder to apply evidence-based treatments and increases the risk of medication interactions. Understanding patterns of polysubstance cravings is critical for designing treatment reflective of the realities patients face.
What our data show
Due to low assessment completion (~64%) and a maximum of two reportable cravings on the cravings assessment, polysubstance craving is likely not fully reflected in patient data available for analysis.
- Among patients who completed the cravings assessment, 31% reported cravings for a second substance at admission (7,907 of 25,848).
- Among all patients diagnosed with an SUD, 48% had at least one additional SUD diagnosis (83,208 of 172,404).
- Patients with two SUD diagnoses were more likely to report cravings for two substances:
- 43% among those with two SUD diagnoses (6,216 of 14,347),
- vs 15% among those with one SUD diagnosis (1,691 of 11,501).
Inhalant and nicotine use disorders were excluded due to low prevalence and lower relative severity, respectively.
Patterns of polysubstances craved upon admission
Craving patterns varied by diagnostic category. We categorized craved substances as “same” or “different” than the primary diagnostic category (e.g., opioid cravings and opioid use disorder are “same”). Across diagnostic categories, stimulants and opioids emerged as the most frequently “different” craving, reflecting the central role of these substances in polysubstance use among individuals entering inpatient treatment.
Importantly, within diagnostic categories, craving frequency, intensity, and duration were similar for “same” and ”different” substances. The one exception to this was among individuals with opioid‑related disorders, where cravings were strongest when opioids were also the craved substance. Primary and secondary craved substances also had similar craving frequency, intensity, and duration. Together, these findings suggest secondary cravings are clinically significant; they represent a meaningful and active component of patients’ substance use risk profile.
Does polysubstance craving impact treatment outcomes?
For admission‑to‑discharge change scores on the Brief Substance Craving Scale (BSCS)[6], patients with polysubstance cravings did not differ meaningfully from patients reporting single‑substance cravings. Similarly, across diagnostic categories, no meaningful differences in change scores were observed between patients whose primary diagnostic category were “same” or “different” than their craved substance.
These findings suggest short‑term treatment outcomes, as measured by reduction in cravings, are not impacted by whether or not the craved substance is the same as the primary diagnosis.
Figure 1. Patterns of polysubstance craved upon admission and clinical outcomes (Interactive visual)
Clinical implications
- Polysubstance cravings are common and clinically significant, yet they may not always be fully reflected in records—an observation supported by the low completion rate of admission craving assessments and the finding that roughly 15% of patients with a single SUD diagnosis who completed the assessment reported an additional craving.
- Cravings for a substance different from the primary diagnostic category are similarly frequent, intense and persistent as cravings for same substances.
- Intake assessments, treatment planning, and pharmacologic strategies should explicitly address polysubstance craving, rather than assuming a single‑substance pathway.
Importantly, changes in craving severity during inpatient treatment were similar for patients with and without polysubstance cravings, suggesting current treatment approaches produce comparable short-term reductions in craving even when patients report multiple, sometimes different substance cravings at admission.
References
[1] Cicero TJ, Ellis MS, Kasper ZA. Polysubstance use: a broader understanding of substance use during the opioid crisis. Am J Public Health. 2020;110(2):244-250. doi:10.2105/AJPH.2019. 305412
[2] Grant BF, Saha TD, Ruan WJ, et al. Epidemiology of DSM-5 drug use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions–III. JAMA Psychiatry. 2016;73(1):39-47. doi: 10.1001/jamapsychiatry.2015.2132
[3] Crummy, E. A., O’Neal, T. J., Baskin, B. M., & Ferguson, S. M. (2020). One is not enough: Understanding and modeling polysubstance use. Frontiers in Neuroscience, 14, Article 569. https://doi.org/10.3389/fnins.2020.00569
[4] Liu, Y., Williamson, V., Setlow, B., Cottler, L. B., & Knackstedt, L. A. (2018). The importance of considering polysubstance use: Lessons from cocaine research. Drug and Alcohol Dependence, 192, 16–28. https://doi.org/10.1016/j.drugalcdep.2018.07.025
[5] Petry, N. M. (2003). Single versus multiple drug focus in substance abuse clinical trials research. UCHC Articles – Research, (176). Retrieved from https://digitalcommons.lib.uconn.edu/uchcres_articles/176
[6] Mezinskis, J. P., Honos-Webb, L., Kropp, F., & Somoza, E. (1998). The measurement of craving. Journal of Addictive Diseases, 17(3), 67–85. https://doi.org/10.1300/J069v17n03_06
