What Do You Do With the Patient Using Everything? (Rebroadcast)

Polysubstance use is where addiction medicine stops being a single-problem visit and becomes real clinical triage. When someone is using alcohol, fentanyl, methamphetamine, benzodiazepines, cannabis, nicotine, and whatever else is in the supply, the hardest part is not naming the diagnosis, it’s deciding what to treat first and how to do it safely. We brought back a remastered conversation with Monterey addiction physician Dr Lee Goldman to walk through the thinking that keeps patients alive and keeps clinicians from getting lost in overlapping symptoms.We talk through how we build the “priority list” using the patient’s own reason for coming in, the dysfunction the substance is causing, and objective tools like urine toxicology while remembering that some sedatives may not show up. Dr Goldman explains why alcohol withdrawal risk often rises to the top, how fentanyl changes buprenorphine inductions through precipitated withdrawal, and why unknown medications like Soma or unmentioned methadone can derail an otherwise solid plan. You’ll hear why many clinicians stabilise one withdrawal syndrome at a time, and what harm reduction looks like when “stop everything today” is not realistic.We also get honest about the messy questions: what does sobriety mean when someone says they’re “sober” but still using cannabis, benzodiazepines, or kratom? How do residential, partial hospital, IOP, and outpatient settings change what we can require and what we can monitor? Why is nicotine so normalised in recovery spaces, and when is the right time to address it? Dr Goldman makes a strong case that benzodiazepines may be the toughest substance to treat, especially with anxiety and PTSD in the background, and we close with what’s changing in drug mixes and where behavioural addictions may be heading next.Subscribe to Addiction Medicine Made Easy, share this with a colleague, and leave a review so more people can find the show.To contact Dr. Grover: [email protected]