What Do You Do With the Patient Using Everything? (Rebroadcast)What Do You Do With the Patient Using Everything? (Rebroadcast)
Addiction Medicine Made Easy
Drs Grover and Goldman talk through practical ways to triage and treat patients using multiple substances at once, focusing on safety, harm reduction and realistic definitions of sobriety. Their discussion blends decades of clinical experience with current challenges around alcohol, fentanyl, benzodiazepines, nicotine and cannabis.
41:19•11 Aug 2026
Managing Patients Who Use "Everything": Polysubstance Use Made Practical
Episode Overview
- Focus first on the substance causing the greatest risk of morbidity and mortality, often alcohol, especially with a history of severe withdrawal.
- Obtain detailed histories and use tox screens, knowing that many sedatives and some benzodiazepines may not appear and can complicate withdrawal.
- For polysubstance use, consider treating one withdrawal syndrome at a time to better understand which medications are helping which symptoms.
- Recognise that benzodiazepines are among the hardest substances to taper safely, with few equally effective alternatives for severe anxiety and panic.
- Use harm reduction when full abstinence is unrealistic, while still labelling nicotine and cannabis as addictions and addressing them when patients are ready.
“Once a patient dips into that benzodiazepine well, they'll never drink from another source.”
What can we learn from those who have battled addiction? This rebroadcast brings together decades of clinical experience to tackle one of the trickiest problems in acute care: the patient using "everything" at once. Emergency physician turned addiction specialist Dr Casey Grover chats with Monterey addiction veteran Dr Lee Goldman, whose career started in the late 70s when a hospital floor was turned into an alcohol treatment unit.
With a relaxed, story-driven style, they walk through real-world cases where people show up using alcohol, fentanyl, methamphetamine, benzodiazepines, cannabis, nicotine and more, and clinicians have to decide what to treat first and how to keep them safe.
You’ll hear how Dr Goldman prioritises substances based on risk of "morbidity, mortality," why alcohol and benzodiazepines demand special caution, and how fentanyl has changed the old belief that opioid withdrawal is just "a bad case of the flu." A memorable case of missed soma withdrawal and another of hidden methadone show how incomplete histories and limited tox screens can seriously complicate care.
The conversation also digs into harm reduction and how ideas about "sobriety" have shifted from all-or-nothing abstinence to accepting medication-associated treatment. As Dr Goldman puts it, "once a patient dips into that benzodiazepine well, they'll never drink from another source," capturing just how hard some substances are to taper. Nicotine and cannabis get frank discussion too: both often ignored by patients, both impactful, especially around mood and long-term health.
The episode’s target audience is clear: busy clinicians in emergency and acute care who want practical, evidence-informed ways to triage and treat polysubstance use without losing sight of compassion. If you’re working with patients who use multiple substances or you’re curious how modern addiction medicine thinks through these tangled cases, this one is worth your time—what substance would you put first on the list?
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