The Reality of Polysubstance Use Disorder

John Makohen
12 hours ago
6 min read

Spilled pill bottle with white pills on wooden table, beside a glass of amber liquid.

April 20, 2026

John Makohen, Author

Tom O'Connor, Publisher

Stuck in the Past: Why AA's Alcohol-Only Approach Leaves So Many Behind

It's right there in the name: Alcoholics Anonymous (AA). From the outset, AA clarifies that its focus is alcohol alone. For someone who only struggles with alcohol use, that singular focus might be enough.

But what about those of us whose addictions don't fit neatly into a single category?

What about the countless people battling poly-substance addiction — mixing alcohol with opioids, cocaine, or even prescription medications? For them, AA's alcohol-centric approach feels like a square peg being hammered into a round hole, leaving little room to address the messy, multi-layered reality of their struggles. This can be highly frustrating, as it appears that their unique challenges are being overlooked, leading to a sense of isolation and desperation.

The Reality of Polysubstance Addiction

Polysubstance use disorder (PUD), formerly polysubstance abuse, is a condition where an individual uses more than one substance, such as alcohol and opioids, or cocaine and prescription medications, and follows a pattern of use that affects their health and quality of life. It's challenging to determine the exact impact of each substance on the body, and the effects can be life-threatening. This mental health condition is treatable, but relapses are possible.

The truth is, addiction doesn't often come in neatly labeled boxes. According to the National Institute on Drug Abuse, poly-substance use — when someone regularly uses more than one substance, such as alcohol and opioids, or cocaine and prescription medications — is an everyday reality for many in the addiction community.

Alcohol is often just one piece of the puzzle. It's the glass of wine paired with opioids for pain relief or the beer that washes down a few pills. Addiction is rarely isolated, and yet AA continues to treat it as though alcohol exists in a vacuum.

When I first stepped into an AA meeting, I was desperate for help. But as I listened to people share their stories, I realized there was an elephant in the room.

Nobody was talking about anything but alcohol. I couldn't relate to the language or the solutions because, for me, alcohol wasn't the whole story.

I wasn't just drinking. I was using heroin to numb my pain. The focus on alcohol felt like a glaring omission — a refusal to acknowledge the full spectrum of addiction that so many of us face.

AA's Alcohol-Centric Lens

AA's foundational philosophy was built in the 1930s when alcohol was the primary substance of abuse.

At the time, the concept of addiction was still largely misunderstood, and the idea of recovery programs for anything other than alcohol was almost nonexistent.

But the world has changed dramatically since then. The opioid epidemic, the rise of stimulant use, and the widespread availability of prescription medications have created a landscape of addiction that is far more complex than anything AA's founders could have imagined. Despite this, AA has remained steadfast in its singular focus on alcohol. The language of the Twelve Steps, the stories shared in meetings, and even the Big Book itself are steeped in an alcohol-centric narrative.

For someone struggling with poly-substance addiction, this can feel alienating at best and downright dismissive at worst. It sends an implicit message: if alcohol isn't your primary issue, maybe this isn't the place for you.

The Harm of Ignoring Other Substances

By narrowing its focus to alcohol, AA fails to address the interconnected nature of addiction. This isn't just a matter of semantics; it has real consequences for people seeking recovery.

Poly-substance addiction often involves unique challenges that AA's framework can't adequately address. For example, the withdrawal process for someone using both alcohol and benzodiazepines is vastly different from alcohol alone. The same goes for the psychological triggers and patterns of use associated with other substances.

Ignoring these nuances leaves people with poly-substance addiction underserved and at greater risk of relapse. Beyond the physical and psychological aspects, AA's alcohol-centric approach can also reinforce stigma.

It creates a hierarchy of addiction, where alcohol is treated as the "acceptable" addiction to talk about, while other substances remain taboo.

This stigma can discourage people from being honest about their struggles, leading them to feel even more isolated in a space that's supposed to be safe and supportive.

The Need for Broader Recovery Strategies

Addiction isn't just about the substance; it's about the person. Recovery should be centered on addressing the root causes of addiction and providing tools to navigate a wide range of challenges. This comprehensive approach is urgently needed, as the current focus on alcohol often leaves little room for it. The time to broaden our understanding of addiction and recovery is now.

Unfortunately, AA's rigid focus on alcohol often leaves little room for this kind of holistic approach. The Twelve Steps, while valuable to some, don't account for the complexities of trauma, mental health, and co-occurring disorders that often accompany poly-substance addiction.

Alternative recovery models, such as SMART Recovery and Refuge Recovery, offer more inclusive frameworks. These programs emphasize evidence-based strategies, mindfulness, and self-empowerment, allowing individuals to address their addiction in a way that's tailored to their unique experiences. They recognize that addiction isn't just one thing and that recovery requires flexibility and adaptation to meet the needs of each person. It's time for recovery programs to be as diverse as the people they serve.

They recognize that addiction isn't just one thing and that recovery requires flexibility and adaptation to meet the needs of each person.

Breaking the Silence on Polysubstance Use Disorder (PUD)

If AA wants to remain relevant in today's addiction landscape, it needs to start addressing the realities of poly-substance use. This doesn't mean abandoning its focus on alcohol but rather expanding its scope to include other substances and the challenges they bring.

It starts with creating space in meetings for open and honest conversations about poly-substance addiction. Instead of framing recovery as an "alcohol problem," AA could adopt language that reflects the broader realities of addiction.

Sponsors and meeting leaders could also benefit from training on how to support individuals with poly-substance addiction. This doesn't mean turning sponsors into therapists, but equipping them with the knowledge and empathy to guide people through more complex recovery journeys.

Recovery literature is a powerful tool for inspiration and guidance. But when it only reflects a narrow view of addiction, it can leave many feeling unseen and unheard. It's time to update this literature to reflect the diverse experiences of addiction and offer hope and support to all who seek it. This update is crucial to ensure that everyone feels represented and supported throughout their recovery.

Recovery Is About the Individual, Not the Substance

At its core, recovery isn't about what you used; it's about who you are and who you want to become. It's about healing the wounds that led to addiction in the first place and building a life worth staying sober for.

This is why it's so crucial for recovery programs to prioritize the individual over the substance. People fall through the cracks when recovery is treated as a one-size-fits-all solution. When tailored to each person's unique needs, it becomes a powerful tool for transformation.

A Call for Inclusivity

The world of addiction is evolving, and recovery programs need to grow with it. AA has played a monumental role in shaping the recovery landscape, but is not immune to criticism or change.

AA expanding its focus to include polysubstance addiction isn't just about staying relevant; it's about saving lives. It's about creating a space where everyone feels seen, heard, and supported, regardless of what brought them to the table.

Recovery is a messy, complex, and deeply personal process. It doesn't fit neatly into boxes and doesn't conform to outdated narratives. By adopting a broader, more inclusive approach, we can create recovery spaces that more accurately reflect the diversity of addiction experiences. Because at the end of the day, it's not about alcohol, opioids, or any other substance. It's about people, and people deserve better.

Have you experienced the limitations of AA's alcohol-centric approach?

What broader strategies have worked for you in addressing poly-substance addiction?

John Makohen also authored two influential books: A Heroin User's Guide to Harm Reduction: Staying Alive in the Age of Fentanyl and Xylazine and Resilience: Building Strength in Early Recovery. The first is a bold, honest survival manual for people who use drugs in today's overdose crisis. The second book is a straightforward guide with practical strategies for building strength and confidence during early recovery.