Keywords

Susan is a 20-year-old female college student with an alcohol use disorder, who was recently charged with driving under the influence (DUI) . Over the course of the past year, she has blacked out on five separate occasions while intoxicated. After one of her blackouts, she awoke on an inpatient medical ward, where she was treated for alcohol poisoning.

A careful history reveals that Susan began drinking beer at the age of 15. Over the past year, her alcohol use has escalated from two to three bottles of beer (12 oz./bottle ≈ 5% alcohol) on one or two occasions per month to two to three glasses of distilled spirits (1.5 oz./glass ≈ 40% alcohol) 5 days per week. Her drink of choice is currently whiskey. She enjoys the smoky taste and usually has two to five glasses of whiskey after returning home at the end of the day. Her drinking has caused her to oversleep and miss class. On one occasion, she attended class while intoxicated. She often drinks before going out with friends, because she feels like alcohol decreases her social anxiety and allows her to be her “true self.” She wants to stop using alcohol due to her recent legal trouble, but is worried that she will not have the strength to resist her alcohol cravings.

Susan’s last drink was approximately 18 h ago, and her urine drug testing is unremarkable for other substances. On laboratory screening, her liver function tests are within normal limits, her creatinine is 1.0, and her glomerular filtration rate is >60 mL/min.

Considerations

What medications would you consider prescribing to Susan for alcohol use disorder? Which medication is the most appropriate at this time (Table 17.1)?

Table 17.1 Medications for alcohol use disorder
Full size table

Since Susan does not live with her family or a partner that is involved in her clinical care, there is nobody to supervise, support, and reinforce disulfiram adherence at home. This lack of medication oversight limits the effectiveness of disulfiram in the outpatient setting [9]. While acamprosate appears to be effective in adults, its three times daily dosing can make adherence challenging.

Given Susan’s normal liver function, negative UDS, and recent alcohol use, her treatment team advises starting naltrexone. If Susan tolerates the oral formulation of naltrexone well, she will be offered naltrexone IM (Vivitrol®), which will likely facilitate medication adherence.