Psychiatry

PCP submission

22-year-old Caucasian female to establish care.

Her medical history is remarkable for alcoholism. She endorses drinking 750 mL of vodka or more per day. She noted at that time that any time she tried to cut back or stop that she would start have serious withdrawal symptoms. She reached out for help and was admitted to a 30 day inpatient treatment program. She was discharged earlier this month with a prescription for oral naltrexone for relapse prevention. The naltrexone made her feel like a zombie as well as nauseous. She took it for less than a week and stopped taking it when she immediately relapsed. She is now drinking 2 cans of Four Loco daily which is a 14% alcohol beverage that comes in 24 ounce cans. The treatment center intended to administer Vivitrol prior to her discharge but it was unavailable. She would like to try this now.

She states that she likes drinking and being drunk but knows that it will have long-term consequences. One barrier to quitting is that she doesn’t sleep well without alcohol. In the treatment center she was prescribed doxepin but was not provided a prescription when she was discharged. She has tried melatonin which she does not like because it prevents her from dreaming and she has very vivid dreams that she likes to have. She thinks that mental health counseling would be helpful.

Relevant medical history is alcoholism in her father’s family. Her father died in his early 40s from liver failure secondary to alcohol abuse.

Would it be appropriate to administer Vivitrol prior to discontinuing her current drinking? Obviously it would be contraindicated if she was using narcotics. I would like to do this and then help her with outpatient discontinuation with a benzodiazepine and gabapentin.

Specialist response

Hi. Thank you for sharing your consult. This is a challenging situation. Because she experienced feeling like a zombie and nausea on Naltrexone, there’s the possibility that she can experience that on Vivitrol. Is she willing to accept the risk of those side effects if she is administered Vivitrol? You might find this Vivitrol information helpful: https://www.vivitrol.com/content/pdfs/prescribing-information.pdf. 

“1 INDICATIONS AND USAGE Treatment with VIVITROL should be part of a comprehensive management program that includes psychosocial support. 1.1 Alcohol Dependence VIVITROL is indicated for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration.”

As you can see, the recommendation is for her not to be actively drinking at the time of Vivitrol administration. It also must be part of a comprehensive treatment program that includes psychosocial support, for which you have referred her to a local counselor. You can also recommend AA, Smart Recovery, and Celebrate Recovery. You might explain to her that the factors that contributed towards drinking in the first place (precipitating factors) are different than ones that maintain drinking (perpetuating factors). She may not sleep well because of alcohol withdrawal and the alcohol’s impact on creating a hyperexcitable state. So she’s not treating underlying insomnia with alcohol. She’s treating an alcohol complication with alcohol. Doxepin for insomnia is reasonable. If not already a priority, I would emphasize enhancing the therapeutic alliance for the time being. This would facilitate her willingness to trust you, experience you as caring, and follow your recommendations. You can ask her what she’s passionate about in life. What gives her meaning and purpose? Who’s important to her? Does she regularly see them? How can she structure her days? This can connect to motivational interviewing strategies that you can use to enhance her engagement in recovery.

You might purchase a book on MI in the Primary Care Setting. Research indicates that strong patient-provider relationships improve health outcomes: Kiesler, Donald J. & Auerbach, Stephen M., 2003. “Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex,” Social Science & Medicine, Elsevier, vol. 57(9), pages 1707-1722, November. https://www.medtronic.com/content/dam/medtronic-com/global/Corporate/Initiatives/harvard-business-review/downloads/strong-patient-provider-relationships-drive-healthier-outcomes-hbr.pdf https://www.ajmc.com/journals/issue/2018/2018-vol24-n11/effects-of-a-communitybased-care-management-model-for-superutilizers.

As you are aware, benzodiazepines like Librium (or Lorazepam if there is liver dysfunction) are used during alcohol withdrawal management. Although the research is limited for outpatient benzodiazepine use for alcohol withdrawal management, the evidence indicates that benzodiazepines in the outpatient setting actually increase the risk of alcohol relapse. Additionally, benzodiazepines are associated with an increased risk of AUD-related hospitalizations and mortality in people with AUD  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8359433/pdf/ADD-116-1990.pdf.

The only circumstances when you could offer Librium 50mg (or Lorazepam 2mg) per CIWA is if she lives with someone who can administer the Librium, can follow up frequently, doesn’t have significant organ dysfunction, doesn’t demonstrate DTs, and doesn’t have an underlying seizure disorder. For a fixed dose schedule, the same recommendations apply. Fixed-schedule regimen Administer one of the following medications every 6 hours: Chlordiazepoxide, four doses of 50 mg, then eight doses of 25 mg Diazepam, four doses of 10 mg, then eight doses of 5 mg Lorazepam, four doses of 2 mg, then eight doses of 1 mg Provide additional medication as needed when symptoms are not controlled (i.e., the CIWA-Ar score remains at least 8 to 10 points).

Here is an article about ambulatory alcohol withdrawal management: https://www.aafp.org/afp/2005/0201/p495.html#afp20050201p495-t4 Thiamine 100mg po daily ASAP x 14 days will be essential to avoid Wernicke’s Encephalopathy. During the acute alcohol withdrawal phase, which is typically the first few days after the last drink, alcohol withdrawal signs/symptoms include tremors, anxiety, nausea, insomnia, perspiration, elevated heart rate, and elevated BP. Severe withdrawal phenomena include alcohol withdrawal seizures and delirium tremens. The highest risk period for acute symptomatic seizures is from about six hours from the last drink to 48 hours from the last drink. Unprovoked seizures can occur up to 14 days from the last drink. The DTs can present from about two days to 14 days from the last drink.

To assess risk of severe withdrawal phenomena, you can ask the following questions. Does your patient have a history of severe alcohol withdrawal experiences, including withdrawal seizures or DTs? When did they occur after the last drink? For how long was she hospitalized? Does she have an underlying seizure disorder? Does she have severe medical disease or organ dysfunction? When was her last drink? How much was she drinking and for how long? Is she experiencing current hallucinations or confusion? To manage acute and post acute withdrawal symptoms and decrease the risk of severe withdrawal phenomena, you might use Gabapentin 300mg tid titrated q 3 days, if indicated, up to 900mg tid. You might use it for the first 1-2 months after alcohol cessation then taper off. Sedation, dizziness, and peripheral edema are main possible side effects. When one entertains the idea of “tapering” alcohol use, there is an assumption that the person with the addiction can control the drinking. A core feature of addiction is loss of control. When a patient speaks to you in a sober mental state and commits to something, that same person can’t predict her behavior when intoxicated. So complete alcohol cessation is imperative at the start.

In terms of alcohol use disorder medications, here are a few considerations for your general awareness. As you know, these are evidence-based when part of a comprehensive treatment plan that includes psychosocial interventions. Disulfiram 250mg-500mg qhs works best in highly motivated people who are in structured programs and the patients are observed when taking it. It interrupts the metabolism of alcohol, so patients get physically sick. Rarely it can result in arrhythmias or death, so generally should be avoided except for those specific circumstances. Regular LFT monitoring is important. Campral 333mg up to 666mg tid is a reasonable option that can be started after the acute alcohol withdrawal period ends, but is dosed TID, so might be a difficulty with medication adherence. It doesn’t impact hepatic functioning so can be prescribed to people with liver dysfunction or disease. You might find this resource helpful: https://www.ncbi.nlm.nih.gov/books/NBK64035/ “The effectiveness and safety of acamprosate have been evaluated for up to 1 year. The length of time a particular patient takes acamprosate will be determined, ideally, with input from the prescribing professional, the specialty treatment provider, and the patient. Discontinuation of acamprosate may be considered once a patient has achieved stable abstinence from alcohol, reports diminished craving, and has established a sound plan and support for ongoing recovery. Acamprosate therapy also may be discontinued if a patient is not adhering to the medication regimen. Acamprosate should not be discontinued just because a patient returns to alcohol use. There is no withdrawal syndrome associated with discontinuing acamprosate, and it is not necessary to taper the dose.” Naltrexone 25mg qhs up to 50mg qhs can be used for people after the initial acute withdrawal period ends. Regular LFT monitoring will be important. While a person takes Naltrexone, you can monitor LFTs at baseline, 1 month, 3 months, 6 months, then annually. The research studies assessed the effectiveness of Naltrexone for up to four months. In practice regular discussions with the patient about pros/cons of continuing Naltrexone are important. You might consider stopping Naltrexone when the person no longer has alcohol cravings, has identified triggers to drink alcohol, has learned effective coping skills, has a solid sober support network, has a solid relapse prevention plan, and remains highly motivated for recovery. Below is a link to the SAMHSA Medication Treatment for Alcohol Use Disorder Guide: https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4907.pdf Please feel free to contact me with additional questions!

PCP follow up

 I can’t begin to thank you enough for this incredibly thoughtful response. All of this advice is well taken and will definitely help me to be to be the most effective part of her care that I can be.

Specialist follow up

Hi. Thank you for your incredibly kind words. I’m glad that you found the response helpful. Good luck!