A 42-year-old man comes to the office for a follow-up. He has a history of gastroesophageal reflux disease, hypertension, and alcohol use disorder. Last year, the patient was hospitalized for acute gastritis. During the hospitalization, he went into alcohol withdrawal that was treated with chlordiazepoxide. The patient was abstinent for 2 weeks following discharge but then started drinking 2 or 3 beers several times a week. Over the past several months, he has been drinking 6-10 beers daily. The patient says, "I want to cut down, but the cravings are too strong." He fears he will lose his job and family if he continues to drink. He has had a history of alcohol abuse since age 14 and has smoked 1.5 packs of cigarettes daily for the past 12 years. The patient does not use illicit drugs. There is a family history of alcohol abuse in his mother and heroin abuse in his brother. Vital signs and physical examination are within normal limits. In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy for this patient's alcohol use disorder?

Question

A 42-year-old man comes to the office for a follow-up.  He has a history of gastroesophageal reflux disease, hypertension, and alcohol use disorder.  Last year, the patient was hospitalized for acute gastritis.  During the hospitalization, he went into alcohol withdrawal that was treated with chlordiazepoxide.  The patient was abstinent for 2 weeks following discharge but then started drinking 2 or 3 beers several times a week.  Over the past several months, he has been drinking 6-10 beers daily.  The patient says, "I want to cut down, but the cravings are too strong."  He fears he will lose his job and family if he continues to drink.  He has had a history of alcohol abuse since age 14 and has smoked 1.5 packs of cigarettes daily for the past 12 years.  The patient does not use illicit drugs.  There is a family history of alcohol abuse in his mother and heroin abuse in his brother.  Vital signs and physical examination are within normal limits.  In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy for this patient's alcohol use disorder?

Quizplus · Accepted Answer

Although this patient desires to reduce his alcohol intake, he is unable to control his strong cravings and is drinking increasing amounts. Pharmacotherapy should be considered in patients with moderate to severe alcohol use disorders. 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. Naltrexone has been shown to decrease alcohol craving, reduce heavy drinking days (defined as >5 drinks for men and >4 for women), and increase days of abstinence. It can be initiated while the patient is still drinking. It is contraindicated in patients taking opioids as it can precipitate withdrawal, and in those with acute hepatitis or liver failure. Acamprosate, which is primarily used to maintain abstinence, should be avoided in patients with significant renal impairment. (Choices A and F) Buprenorphine is an opioid partial agonist used in the treatment of opioid use disorder and pain management. Valproate is an anticonvulsant agent used in the treatment of epilepsy and bipolar affective disorder. Neither of these medications is recommended for the treatment of alcohol use disorder. (Choices B and G) Bupropion and varenicline are first-line pharmacologic therapies for smoking cessation, not alcohol use disorder. (Choice C) Benzodiazepines (eg, chlordiazepoxide) are indicated for the treatment of moderate to severe alcohol withdrawal. They do not treat alcohol use disorder and have a high risk of abuse. (Choice D) The aldehyde dehydrogenase inhibitor disulfiram is an aversive agent that causes an unpleasant physiologic reaction (tachycardia, flushed skin, headache, nausea, vomiting) when alcohol is consumed. It can be used only in abstinent patients and would not be preferred in this patient who is actively drinking. Candidates for disulfiram must be highly motivated or take the medication in a supervised setting as a patient may skip a dose to avoid the medication's aversive reaction when alcohol is desired. It is considered a second-line agent that is used when naltrexone and acamprosate are either ineffective or contraindicated. Educational objective: Naltrexone is a first-line pharmacotherapy for alcohol use disorder that decreases craving and heavy drinking. It can be initiated in opioid-free patients without significant liver disease who are still drinking. References: Reductions in alcohol craving following naltrexone treatment for heavy drinking. (http://www.ncbi.nlm.nih.gov/pubmed/27402770) Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24825644)

A 42-Year-Old Man Comes to the Office for a Follow-Up