Case Study Report: 11

Opening Statement: Case 2013 is a man with a long history of treatment-refractory alcoholism as well as a schizoaffective disorder who showed gradual but steady improvement on treatment with naltrexone. This study subject's strong alcohol craving and concurrent psychotic disorder make him of particular interest.

Patient Background Information: This 41-year-old, married white man was employed part-time in a supported job in sales and is active in the clubhouse for seriously mentally ill patients in his home city. He had completed 2 years of college. He met criteria for severe alcohol dependence (satisfying all nine DSM-III-R criteria), and had a history of marijuana abuse without dependence. Relevant medical history was significant for recurrent melena due to gastritis, chronic bronchitis, lithium (lithium carbonate)induced edema and diarrhea, haloperidol (Haldol)-induced tremor and Parkinsonism, and anticholinergic effects of benztropine (Cogentin). His medications were lithium, Haldol, Cogentin, propranolol (Inderal), and sertraline (Zoloft). He had several prior episodes of depression, psychosis, and mania. He had been drinking heavily for 12 years, typically about 58 drinks per week. He had-been enrolled in alcoholism treatment once previously for 2 months as an outpatient. On study enrollment, he was seeking alcoholism rehabilitation for the second time. He had a history of alcohol-induced depression, marital discord with threatened divorce, homelessness, job losses, and increased noncompliance with prescribed psychotropic medications. His longest sustained period of abstinence was approximately 1 month in the previous 8 years. Family history was positive for alcoholism.

Naltrexone Treatment and Results: This subject began treatment with naltrexone at a daily dose of 25 mg on day 0, and increased to a daily dose of 50 mg on day 14 as he had resumed drinking. He reported a marked decrease in his desire to drink following the dose increase, and then drank only approximately 1 to 2 days per week. Over the first 6 months during which he continued to take the 50-mg dose, his drinking intensity and frequency declined gradually. Because of his preference and persistent drinking, his dose was increased to 100 mg daily, which was well tolerated. His drinking has now ceased altogether for 3 weeks. The subject has increased his work hours, and he now owns and operates a small shop at a local shopping mall where he sells and resells model trains. His marital relationship, medication compliance, and severity of psychiatric symptoms have all improved during treatment with naltrexone. He continues to. attend a dual diagnosis relapse prevention skills group on a regular basis, and is now the social chairman for the group.

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