Understanding Polysubstance Use and How to Make Health-Enhancing Choices

Polysubstance use, or the mixing of two or more substances, is a dangerous but common practice. Individuals may mix substances intentionally, including to enhance or counteract the effects of other substances, or unintentionally, when substances are unknowingly mixed with other drugs or when people are unaware that mixing certain substances can have adverse effects.^2,3 Teens especially may be unaware of the dangers of mixing substances such as alcohol, caffeine, and other drugs. It is important for students to learn the risks of polysubstance use and how to make risk-aware decisions.

This activity is designed to be delivered in an in-person classroom setting. It can also be adapted as a virtual assignment or an assignment for students to complete at home.

Student Objectives

Students will be able to…

• Use the DECIDE^1,4 model to analyze a decision about polysubstance use.

Methodology and Assessment

Using the scenarios in the To Mix or Not to Mix worksheets below, have students complete the DECIDE model to progress through the stages of the decision-making process. Students should explain what information is needed to inform a decision to improve health, possible options, possible outcomes of each option (including Healthy and Unhealthy outcomes), which decision they would choose, and why.

Activity

Teacher prompts are in italics.

Introduce the Skill

Everyone in this classroom can make informed decisions. Some choices are harder to make than others, especially if you feel pressured by those around you. Today, we are going to practice a decision-making process called DECIDE. Though the process is useful in any situation, we are going to apply it to scenarios involving polysubstance use. We will go through an explanation and practice scenario together, and then you will divide into four groups to work through the DECIDE process on your own.

Mixing substances, such as alcohol or other drugs, is known as polysubstance use. Polysubstance use happens when two or more substances are taken together at the same time or each are taken separately, but a short time apart from each other. It is considered polysubstance use whether the drugs are mixed intentionally or unintentionally, even if they are mixed accidentally or unknowingly.²

Someone may purposely take a drug, or drugs, to increase or decrease the effects of a different substance or if they want to experience the effects of the combination.² For example, someone may take their prescribed Adderall medicine and then drink alcohol once they are done with their schoolwork.

On the other hand, someone may unintentionally take a drug, or drugs, that have been mixed or cut with other substances, like fentanyl, without their knowledge.^2,3 These drugs are especially dangerous, because it can be impossible to tell that they have been mixed with other substances, and in what quantities.

Whether intentional or not, mixing substances is never safe because the effects from combining drugs are often stronger, more unpredictable, and even deadlier than those from one drug alone.²

Optional: Show the What Happens When Drugs Are Combined? video (2:27).

If a person decides to take a drug, the DECIDE model is an important tool for determining how to not consume more than one substance at a time.

Ask: What skills might someone already have to help them make informed decisions about mixing substances?
Possible answers: observation skills, critical thinking, knowledge about substances and the dangers of mixing them. This will allow you to determine what foundation students already have for this skill.

Describe the Skill

There is an acronym, called DECIDE,^1,4 that can help you remember the steps of the decision-making process. Let’s review the steps:

• D — First, define the problem or decision to be made. Some general things to consider may include:
  • Who is involved in this decision?
  • What information is missing to be able to make an informed decision?
• E — Then, explore the options. The model is most effective when at least three possible options of the situation are considered.
• C — Next, consider the outcomes. For each option, work to identify possible outcomes that are both positive and negative.
• I — Finally, identify the best option. This is an important step, so remember to consider all the options and possible outcomes identified in the first two steps. It may be helpful to ask yourself, “Is this option going to maintain or improve my health and well-being?”
• D — Now, it’s time to develop a plan and act. Consider the following questions:
  • How will the decision be implemented? 
  • What resources or support are necessary to follow through on this decision? 
• E — Lastly, and often forgotten, evaluate the decision. Reflect on the decision and make note if the outcome was as anticipated and if it makes sense to make the same decision or choose differently in the future.

Model the Skill

We are now going to go through an example of using the DECIDE model together.

Using Appendix 1 below, go through the scenario with the students. You can present the worksheet, share copies with students, or read the scenario and work through the DECIDE model on a whiteboard or blackboard.

Read through the scenario with students.

Xaden, a 16-year-old student, started experiencing migraines earlier in the year. Xaden’s doctor prescribed him a medication to help with the migraine symptoms. When he got a migraine an hour ago, Xaden took the medication, but he doesn’t feel like it is working. He knows that his mom also experiences migraines and has a different prescription medication, and he wonders if that medication would work better. Xaden is in a lot of pain; however, he remembers that his doctor said to be careful about mixing prescriptions. Should Xaden take some of his mom’s medication?

Now discuss each step of the DECIDE model with students and ask them how they would apply it to this scenario.

Step 1 in the DECIDE model is to define the problem or the decision to be made. This is already done for us in the scenario. The problem is whether Xaden should take his mother’s medication after taking his own, to relieve his migraine pain.

Step 2 is to explore the options.

Ask: What options does Xaden have in this scenario?

Have students share options and make note of them (on the worksheet, board, etc.). Possible answers include take the medication, not take the medication, take an over-the-counter pain reliever, and seek help from an adult. Once students have finished sharing, move on to step 3.

Step 3 of the DECIDE model is to consider the outcomes of each option. We’ll go through each option we just discussed one by one.

For each option, students came up with in step 2, ask them to share pros and cons. If students shared a significant number of options, and/or time is a concern, only discuss three of the options shared. Then move on to step 4.

Step 4 of the DECIDE model is to identify the best option.

Ask: Given the options we have discussed and the potential outcomes of each option, what is Xaden’s best option? 

Ask students to discuss this as a class. Answers will depend on the options and outcomes discussed in the previous steps. When students have finished discussing, move on to step 5.

Step 5 of the DECIDE model is to develop a plan and act.

Ask: Given what we discussed about Xaden’s options, the pros and cons, and Xaden’s best option, what action should Xaden take and why?

Allow students to discuss the action they would decide to take. They do not need to come to a consensus, but you can use differing opinions as an opening for further discussion. When students have either come to a consensus or discussed their reasoning for different decisions, say:

It is important to remember that it is never a good idea for someone to take prescription medication without their health care provider saying they can. In this case, it is possible that Xaden’s medication and his mother’s medication could have harmful side effects when taken close together or give Xaden too much medication at once. It is also never a good idea for someone to take medication that was prescribed for someone else, as it may have other health risks for them.

Step 6, the last step of the DECIDE method, is to evaluate your decision after the fact.

Ask: Given the information you now have, do you think your decision was the correct one?

When students have had time to discuss their evaluation of their decision, move on to the next section.

Practice the Skill

We are now going to split into groups and work through some scenarios to practice using the DECIDE decision-making model. Once your groups are done, we will share our conclusions and discuss them as a class.

Split the class up into four groups and hand each group one “To Mix or Not to Mix” sheet (Appendix 2).

Work together with your group to read the scenario, which is provided to you. Then, work through the DECIDE decision-making model process to define the problem, explore the options, consider the outcomes, identify the best option, develop a plan to act, and, finally, evaluate your decision.

Give groups time to complete their provided scenario.

Assess the Skill

Have each group present their scenario and their DECIDE decision-making model steps. Allow groups to provide feedback on others’ DECIDE decision-making model steps. Students may or may not know the potential risks of mixing the specific substances in their scenarios. This will mimic real-world scenarios where they may not know the specific risk of certain drug combinations. For each scenario, after students have presented their decision-making steps and given feedback, give students the explanations below.

Jordan: Mixing prescribed painkillers with illicit drugs can lead to dangerous interactions and increase the risk of becoming sick or dying.

Emily: The medication may contain ingredients that can interact negatively with alcohol, potentially leading to increased drowsiness, impaired coordination, possible liver damage, or death.

Arun: Mixing anxiety medication with other substances, such as the caffeine in energy drinks, can lead to unintended side effects and impact overall well-being.

Elijah: Using non-prescribed Adderall medication purchased online and/or marijuana vape products are each risky, and mixing them can have unpredictable effects. Drugs purchased online could contain harmful additives or other substances that could be harmful to your health and even lead to overdose or death.

Anyone could find themself in these scenarios. It’s important to remember that you should never take drugs unless they are prescribed for you by a doctor, and mixing drugs can have unpredictable effects. The effects from combining drugs may be stronger and more unpredictable than one drug alone and can be deadly. You now have a tool, the DECIDE model, that you can use to help you make informed choices about alcohol or other drugs, or for any other tough choices you might face.

References

1. Guo KL. DECIDE: a decision-making model for more effective decision making by health care managers. Health Care Manag (Frederick). 2008 Apr-Jun;27(2):118-27. doi: 10.1097/01.HCM.0000285046.27290.90.
2. Polysubstance Use Facts (2022). Centers for Disease Control and Prevention. 
3. Polysubstance Overdose (2024). Centers for Disease Control and Prevention. 
4. Mental and Emotional Health: Types of Health (2009). Department of Defense.