A 48-year-old man comes to the office for his yearly follow-up visit. The patient's medical history includes hypercholesterolemia, hypertension, and alcohol use disorder. He says, "I am going through a divorce, and it has been hard not to drink. It's depressing to come home to an empty house, and I usually end up in a bar on my way home from work." The patient consumes 2 pints of vodka daily and admits that he keeps a bottle of vodka at work so that he can drink during the day. He has a history of blackout episodes during intoxication. Last year, the patient was hospitalized after having a seizure and was treated for alcohol withdrawal. Following discharge, he was referred to an outpatient substance abuse program but did not attend because, "I thought I could stop on my own." The patient has lived alone since his wife moved out of the house and works in insurance sales. His longest period of sobriety is 3 weeks. He does not use illicit drugs but has smoked a pack of cigarettes daily for 20 years. The patient says, "I want to stop drinking, but the cravings are just too strong." In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy?

Question

A 48-year-old man comes to the office for his yearly follow-up visit.  The patient's medical history includes hypercholesterolemia, hypertension, and alcohol use disorder.  He says, "I am going through a divorce, and it has been hard not to drink.  It's depressing to come home to an empty house, and I usually end up in a bar on my way home from work."  The patient consumes 2 pints of vodka daily and admits that he keeps a bottle of vodka at work so that he can drink during the day.  He has a history of blackout episodes during intoxication.  Last year, the patient was hospitalized after having a seizure and was treated for alcohol withdrawal.  Following discharge, he was referred to an outpatient substance abuse program but did not attend because, "I thought I could stop on my own."  The patient has lived alone since his wife moved out of the house and works in insurance sales.  His longest period of sobriety is 3 weeks.  He does not use illicit drugs but has smoked a pack of cigarettes daily for 20 years.  The patient says, "I want to stop drinking, but the cravings are just too strong."  In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

Explanation: This patient has a history of alcohol use disorder and has required treatment for withdrawal in the past. He is actively drinking, and his consumption has likely increased under the stress of his divorce. He has been unable to stop on his own for more than a few weeks at a time and experiences strong cravings. Pharmacotherapy for alcohol use disorder is underused and should be considered in patients, such as this one, who have moderate to severe alcohol use disorder and who are unable to achieve abstinence with psychosocial treatment alone. Pharmacologic treatments target the reinforcing effects of alcohol by modulating the function of opioids and glutamate. First-line pharmacotherapy for alcohol use disorder includes naltrexone, a mu opioid receptor antagonist, and acamprosate, a glutamate modulator. Naltrexone 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. It can be initiated while the patient is still drinking. It is contraindicated in patients taking opioids and in those with acute hepatitis or liver failure. A depot form of naltrexone can be used when there are concerns regarding nonadherence. (Choice A) Bupropion is used to treat depression and aid smoking cessation. It is not effective in alcohol use disorder. In addition, bupropion is associated with an increased risk of seizures and is contraindicated in patients with a predisposition to seizures. (Choice B) Benzodiazepines (eg, chlordiazepoxide) are used to treat moderate to severe alcohol withdrawal. They have no role in the treatment of alcohol use disorder and carry risks of abuse and dependence. (Choice C) Disulfiram is an aversive agent reserved for patients who are abstinent. It inhibits aldehyde dehydrogenase, which causes an unpleasant physiologic reaction when alcohol is consumed. 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 would not be preferred in this patient who is actively drinking and lives alone. (Choice E) Varenicline is a first-line pharmacotherapy for smoking cessation. It would not treat this patient's alcohol use disorder. Educational objective: Naltrexone is a first-line treatment for moderate to severe alcohol use disorder. It decreases cravings and heavy drinking and can be initiated in opioid-free patients who are still drinking. References: Review article: pharmacotherapy for alcohol dependence - the why, the what and the wherefore. (http://www.ncbi.nlm.nih.gov/pubmed/28220511) 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 48-Year-Old Man Comes to the Office for His Yearly