• Alcohol use disorders are extremely common, with the majority of people having some lifetime exposure to alcohol and nearly a third of people meeting criteria for an alcohol use disorder at some point in their lives.
• Thoughtful selection of a treatment setting that matches the pa- tient’s needs at the time can be an important part of treatment planning.
• Determining whether psychiatric symptoms are substance in- duced or due to a co-occurring illness can be challenging, but ultimately, correctly identifying and treating co-occurring illness will aid patients in their recovery.
References
Anton RF, O’Malley SS, Ciraulo DA, et al: Combined pharmacotherapies and behavioral interventions for alcohol dependence. The COMBINE study: a randomized con- trolled trial. JAMA 295:2003–2017, 2006
Hasin DS, Stinson FS, Ogburn E, et al: Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the Na- tional Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychi- atry 64:830–842, 2007
Petrakis IL, Gonzalez G, Rosenheck R, et al: Comorbidity of alcoholism and psychiatric disorders: an overview. Alcohol Research and Health 26:81–89, 2002. Available at: http://pubs.niaaa.nih.gov/publications/arh26-2/81-89.pdf. Accessed February 28, 2013.
Substance Abuse and Mental Health Services Administration: Results From the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No (SMA) 11-4658. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2011
Questions
2.1 Victoria presents to your office reporting depressed mood, anhedonia, poor sleep and appetite, low motivation, and difficulty concentrating for the past 3 months. She has been isolating more and finds that she is tearful sometimes for no reason. She also tells you that during the past 5 years she had been drinking a bottle of wine nightly, but 3 weeks ago she completed a detoxification and is currently still sober. What is the best next step?
A. Schedule the patient for a follow-up in 6 months because she should be sober for that period of time before you can accurately diagnose and treat a mood disorder.
B. Obtain a further history, particularly about her past periods of sobri- ety and any mood symptoms she might have experienced during those times, in order to establish a diagnosis before treatment. C. Start her on low-dose benzodiazepines and taper slowly over the
next month because she may be experiencing residual alcohol with- drawal symptoms.
D. Recommend that she attend Alcoholics Anonymous in her recovery program because sharing her story may improve her mood and help get her out of the house.
The correct answer is B.
Determining whether a patient’s symptoms are substance induced or co- occurring is one of the more challenging aspects of working with patients
with substance use disorders. One way in which we can start to differen- tiate is by establishing a time-course of the development of symptoms. This patient is early in her sobriety, but she may have had more extended periods of sobriety in the past, and the presence or absence of mood symptoms during these periods may aid you in diagnosis. You may also want to ask about time periods prior to the development of habitual sub- stance use. Waiting for 6 months of sobriety after this visit may not be feasible because if she does have a co-occurring mood disorder, leaving it untreated for that period of time will likely jeopardize her sobriety. These symptoms are unlikely to be related only to withdrawal because the pa- tient reports that they existed for several weeks prior to detoxification. Alcoholics Anonymous could be a useful adjunct to her recovery pro- gram, but again this does not address whether she has a mood disorder that could be treated at this time.
2.2 Michael is a 54-year-old man brought in by ambulance to the emergency department after having a witnessed generalized tonic-clonic seizure. He is accompanied by his wife, who provides history because the patient is initially somewhat confused in the postictal phase. She reports that Mi- chael has been a heavy drinker for the past 15 years, drinking up to 1.5 pints of vodka daily, with his last drink about 72 hours prior to the sei- zure. She reports that he had another seizure in the past that was ulti- mately attributed to alcohol withdrawal. You note that he is tremulous and diaphoretic, with a blood pressure of 150/90 and a pulse in the 90s– 100s. His head CT scan is negative. On reevaluation Michael’s mental sta- tus has still not cleared—he is oriented only to name—and he is becoming belligerent, demanding to leave. Which of the following is the most ap- propriate next step?
A. Administer lorazepam 2 mg intramuscularly and admit to inpatient substance abuse rehabilitation unit.
B. Administer lorazepam 2 mg intramuscularly and admit to inpatient detoxification unit.
C. Administer lorazepam 2 mg intramuscularly and discharge him against medical advice.
D. Administer lorazepam 2 mg intramuscularly and admit to inpatient psychiatric unit.
The correct answer is B.
Michael has most likely had another alcohol withdrawal seizure and is currently exhibiting signs and symptoms of alcohol withdrawal. His confusion may be related either to being postictal or perhaps to devel-
oping delirium tremens (DTs). He requires immediate treatment of al- cohol withdrawal (because a history of withdrawal seizures increases the risk for DTs, which carries a 20% mortality rate when untreated), and in- patient detoxification, rather than rehabilitation or psychiatric hospital- ization, would be the appropriate treatment setting for him. Inpatient detoxification is for the most part (varies by state) a voluntary admis- sion, and Michael is refusing treatment; however, his lack of orientation to date or place indicates that he lacks the capacity to make this medical decision, and he can be admitted for potentially life-saving treatment at this time despite his refusal.
2.3 John has a history of opioid use disorder that is now stabilized on meth- adone maintenance. He has been clean from heroin for 10 years but has increased his alcohol consumption and is now drinking a six-pack of beer daily. After completing an outpatient detoxification, he is now at- tending an intensive outpatient program to focus on his recovery from alcohol. He comes to see you in your primary care office because he is interested in medication to help him stop drinking. He says, “Methadone really helped me get back on my feet and kept me away from the heroin. I want to see if there’s a medication that can help me for my drinking problem.” Which of the following could be a useful adjunct to his regi- men? A. Naltrexone. B. Disulfiram. C. Lorazepam. D. Acamprosate. E. B and D. F. A, B, and D. G. All of the above.
The correct answer is E.
Disulfiram, acamprosate, and naltrexone are the only FDA-approved medications for the ongoing treatment of alcohol use disorders. Loraze- pam, although useful in acute detoxification, has not shown any benefit as a “maintenance” medication in the way that methadone has for opioid use disorder. Because John is on methadone, naltrexone (an opioid an- tagonist) would not be an option for him, which leaves disulfiram and acamprosate.