WG has made it through withdrawal without complications thanks to an appropriate management regimen. She would like to consider pharmacological treatment to maintain abstinence. Her LFTs have normalized now that she has been alcohol-free for the past week. She reports taking disulfiram during previous rehabilitation attempts but was unsuccessful, most likely because of adherence issues. Her medical chart indicates she has great insurance so prescription copayments shouldn’t be a problem.
What abstinence medication would be most appropriate for WG?
Belos is a peers example
he Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a scale used to measure alcohol withdrawal symptoms; a total score greater than 15 or history of alcohol withdrawal seizures indicates immediate pharmacological treatment. Long-acting benzodiazepines (i.e., oxazepam, clonazepam and diazepam) remain the gold standard for the management of alcohol withdrawal but is not recommended for outpatient treatment due to risk of misuse and adverse profile when combined with alcohol (Gabbard, 2014).
<p>By enhancing reward pathways associated with dopamine and serotonin, alcohol inhibits glutamate receptor subset N-methyl-D-aspartate (NMDA) and gamma aminobutyric acid (GABA) leading to sedation. As a result, such changes affect neurotransmitter receptors thus contributing to tolerance and dependence (Zaderenko, 2020).
Case study
WG is a 41-year-old female who presented to ER wishing to detox from alcohol. Patient reports history of alcohol dependance, alcohol withdrawal seizures and multiple relapses; her CIWA-Ar is 17. Patient previously tried disulfiram but reports history of non-adherence. Patient is 1 week sober from alcohol and considering pharmacological treatment to maintain abstinence from alcohol; use of medications is denied.
Based on the patient’s history, my recommendation for WG is Naltrexone 380mg IM once monthly. The intramuscular form of Naltrexone is ideal for patients like WG who struggle with compliance and wish to cut back or stop drinking, Naltrexone is effective at reducing alcohol consumption and risk of relapse (Gabbard, 2020).
Prior to treatment, it is imperative to rule out/address psychiatric comorbidities and use of opioids. According to Li et at. (2020) alcohol use disorder is associated with an increased risk of subsequent depressive symptoms. In addition to pharmacological treatment, WG can benefit from behavioral therapy and identification of treatment goals.