Opening Statement: What is most interesting about this case is the apparent ability of naltrexone to both diminish the urge to drink and prevent loss of control during a slip. This suggests a dual mechanism of action for the medication. It also has implications for the use of naltrexone in a patient unable to achieve total sobriety.
Patient Background Information: This patient is a 41 year-old, married, white woman who works as a medical secretary. She is a high school graduate with 2 1/2 years of college. Her clinical diagnosis is alcohol dependence on Axis I. She also exhibits some dependent personality traits and characteristics of "battered woman's syndrome”. She has no medical problems other than migraines, for which she takes butalbital (Fiorinal) occasionally. Her family history is positive for alcoholism and for depression. She first drank at age 13, with experimental and recreational use. She developed problem drinking at age 32, during a divorce. She had inpatient alcoholism treatment at (treatment center name deleted) for 28 days following a DWI in December 1992. She was abstinent for only 5 weeks following discharge in 1993, then relapsed to heavy drinking. Prior to study enrollment, she was drinking two to three times per week, up to 15 drinks per occasion (mixed drinks, wine, beer). Alcohol was having a significant negative impact on her life. She had a DWI, loss of jobs, marital stress, an arrest for spousal abuse, and an inability to secure and maintain suitable housing. She reports that she drinks alcohol to avoid isolation and to medicate the pain of her husband's abusiveness.
Naltrexone Treatment and Results: The patient was enrolled in the study on 6/3/94. She has been taking naltrexone 50 mg per day throughout the duration of the study. Her only side effect is fatigue; therefore, she takes her medication at bedtime. After enrollment, the patient remained entirely abstinent for about 4 weeks. on 7/6/94, she had two drinks, felt filled up, and stopped. She claimed she did not need the alcohol and did not want more. She reports that alcohol did not taste different. She was pleased and surprised with-her response. Following her slip, the patient continued to drink episodically, but under relapse criteria (one to three drinks per occasion). on 9/7/94, following a marital altercation, she relapsed. At that time, she said she had run out of naltrexone and was not on the medication. From November 1994 onward, she has continued to drink occasionally, below relapse criteria, at times of extreme stress, such as physical or emotional abuse from her husband. otherwise, she reports few urges to drink. Now in the second extension of the study, she is living apart from her husband, whom she is divorcing. She is holding a steady job, which provides her with a great deal of personal satisfaction. Clearly, her life has been greatly improved.
What is most interesting about this case is the ability of the patient to apparently use naltrexone in combination with her psychosocial treatment, to both diminish her urge to drink and prevent loss of control when she does slip. This suggests a dual mechanism of action for the medication — reducing urge and decreasing the loss of control when one does drink. An issue is the apparent therapeutic use of naltrexone in a nonsober patient. The patient is in an abstinence-oriented treatment program, but is unable to achieve total sobriety. Nevertheless, naltrexone seems to help reduce the patient's urge to drink and to prevent loss of control. Is this an appropriate use of the medication?