A 54-year-old woman comes to the office for her annual health maintenance visit. The patient's medical problems include hypercholesterolemia, gastroesophageal reflux disease, and alcohol use disorder. She was hospitalized for treatment of alcohol withdrawal last year and attended an outpatient substance abuse program after discharge. The patient maintained abstinence for 3 months following completion of the program. Since then, she has attempted to limit her consumption to 1 drink a day; however, since being let go from her job last month, she has started drinking heavily again and currently consumes 8-10 vodka drinks daily. She says, "I thought I could control it on my own, but the cravings are so intense." The patient lives alone and is currently looking for work. She has smoked a pack of cigarettes daily for 30 years but does not use illicit drugs.
Temperature is 36.7 C (98 F) , blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 12/min. BMI is 27 kg/m². Examination shows no abnormalities.
In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy?

Question

Quizplus · Accepted Answer

Pharmacotherapy is underutilized and should be considered in patients with moderate to severe alcohol use disorder and those who are unable to maintain abstinence with psychosocial treatment alone. Medications that target the reinforcing effects of alcohol by modulating opioid and glutamate function are effective. First-line treatment options include naltrexone, a mu-opioid receptor antagonist, and acamprosate, a glutamate modulator. This patient is actively drinking and unable to control strong cravings. Naltrexone can be initiated while she is still drinking; it has been shown to decrease alcohol cravings, reduce heavy drinking days (defined as >5 drinks for men and >4 for women), and increase days of abstinence. A depot form of naltrexone can be used when there are concerns regarding nonadherence. Naltrexone is contraindicated in patients taking opioids and in those with acute hepatitis or liver failure; in these patients, acamprosate is preferred. (Choice A) Bupropion is not effective in alcohol use disorder. It is used in the treatment of depression and for smoking cessation. (Choice B) Benzodiazepines (eg, chlordiazepoxide) are used to treat moderate to severe alcohol withdrawal. They are associated with high risk of abuse and dependence and have no role in the treatment of alcohol use disorder. (Choice C) The aldehyde dehydrogenase inhibitor disulfiram works as an aversive agent by causing an unpleasant physiological reaction when alcohol is consumed. It does not reduce cravings directly. Disulfiram is reserved for abstinent patients who are highly motivated or who take the medication in a supervised setting (a patient may skip a dose to avoid the aversive reaction when alcohol is desired). It is considered a second-line agent and would not be preferred in this patient, who is actively drinking and lives alone. (Choice D) Selective serotonin reuptake inhibitors (eg, fluoxetine) have not demonstrated efficacy in patients who have alcohol use disorder and no comorbid mood or anxiety disorder. Educational objective: Pharmacotherapy is appropriate for patients with moderate to severe alcohol use disorder. Naltrexone is a first-line treatment that decreases cravings and heavy drinking; it can be initiated in patients who are still drinking provided they do not take opioids and have no significant liver disease. __________ References: Review article: pharmacotherapy for alcohol dependence - the why, the what and the wherefore. (http://www.ncbi.nlm.nih.gov/pubmed/28220511) Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24825644) Reductions in alcohol craving following naltrexone treatment for heavy drinking. (http://www.ncbi.nlm.nih.gov/pubmed/27402770)

A 54-Year-Old Woman Comes to the Office for Her Annual