Polysubstance Intoxication: Managing the Unknown

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. ----more---- Looking for this episode's transcript? Download it HERE Get credit for listening! Claim your 0.5 CEs HERE Have an idea for a future episode? Share it with us at education@asam.org. 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