Cases That Test Your Skills

When a patient with chronic alcohol use abruptly stops drinking

Current Psychiatry. 2023 April;22(4):42-46,48 | doi: 10.12788/cp.0349

References

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18. Esser MB, Leung G, Sherk A, et al. Estimated deaths attributable to excessive alcohol use among US adults aged 20 to 64 years, 2015 to 2019. JAMA Netw Open. 2022;5(11):e2239485. doi:10.1001/jamanet workopen.2022.39485

19. The Community Guide. CPSTF Findings for Excessive Alcohol Consumption. Updated June 27, 2022. Accessed December 1, 2022. https://www.thecommunityguide.org/pages/task-force-findings-excessive-alcohol-consumption.html

20. The Community Guide. Alcohol Excessive Consumption: Privatization of Retail Alcohol Sales. Updated June 27, 2022. Accessed December 1, 2022. https://www.thecommunityguide.org/findings/alcohol-excessive-consumption-privatization-retail-alcohol-sales.html

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TREATMENT Pharmacotherapy for alcohol use disorder

As Mr. G’s condition starts to stabilize, he discusses treatment options for AUD with his physician. At the end of the discussion, Mr. G expresses an interest in starting a medication. The doctor reviews his laboratory results and available treatment options.

The author’s observations

Of the 3 FDA-approved medications for treating AUD (disulfiram, acamprosate, and naltrexone), naltrexone has been shown to decrease heavy drinking days^5,14and comes in oral and injectable forms. Reducing drinking is achieved by reducing the rewarding effects of alcohol^5,14 and alcohol cravings.⁵Disulfiram often has poor adherence, and like acamprosate it may be more helpful for maintenance of abstinence.Neither topiramate nor gabapentin are FDA-approved for AUD but may be used for their affects on GABA.⁵ Gabapentin may also help patients experiencing alcohol withdrawal syndrome.^5,15Mr. G did not have any concomitant medications or comorbid medical conditions, but these factors as well as any renal or hepatic dysfunction must be considered before initiating any medications.

OUTCOME Improved well-being

Mr. G’s treatment team initiates oral naltrexone 50 mg/d, which he tolerates well without complications. He stops drinking entirely and expresses an interest in transitioning to an injectable form of naltrexone in the future. In addition to taking medication, Mr. G wants to participate in psychotherapy. Mr. G thanks his team for the care he received in the hospital, telling them, “You all saved my life.” As he discusses his past issues with alcohol, Mr. G asks his physician how he could get involved to make changes to reduce excessive alcohol consumption in his community (Box^5,15-21).

Box

Community efforts to reduce excessive alcohol consumption

Alcohol use disorder is undertreated^5,15-17 and excessive alcohol use accounts for 1 in 5 deaths in individuals within Mr. G’s age range.¹⁸ An April 2011 report from the Community Preventive Services Task Force¹⁹ did not recommend privatization of retail alcohol sales as an intervention to reduce excessive alcohol consumption, because it would instead lead to an increase in alcohol consumption per capita, a known gateway to excessive alcohol consumption.²⁰

The Task Force was established in 1996 by the US Department of Health and Human Services. Its objective is to identify scientifically proven interventions to save lives, increase lifespans, and improve quality of life. Recommendations are based on systematic reviews to inform lawmakers, health departments, and other organizations and agencies.²¹ The Task Force’s recommendations were divided into interventions that have strong evidence, sufficient evidence, or insufficient evidence. If Mr. G wanted to have the greatest impact in his efforts to reduce excessive alcohol consumption in his community, the strongest evidence supporting change focuses on electronic screening and brief intervention, maintaining limits on days of alcohol sale, increasing taxes on alcohol, and establishing dram shop liability (laws that hold retail establishments that sell alcohol liable for the injuries or harms caused by their intoxicated or underage customers).¹⁹

Bottom Line

Patients experiencing alcohol withdrawal can present with several layers of complexity. Failure to achieve acute stabilization may be life-threatening. After providing critical care, promptly start alcohol use disorder treatment for patients who expresses a desire to change.

Related Resources

American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. https://www.asam.org/quality-care/clinical-guidelines/alcohol-withdrawal-management-guideline
American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. American Psychiatric Association Publishing; 2018.

Drug Brand Names

Acamprosate • Campral
Disulfiram • Antabuse
Gabapentin • Neurontin
Naltrexone (injection) • Vivitrol
Naltrexone (oral) • ReVia
Topiramate • Topamax