Case Study Report: 9

Opening Statement: This was the first treatment episode for (name deleted) who enrolled in our program with a history of alcohol, cocaine, and opiate dependence. His case is interesting in that although naltrexone treatment did not eliminate his consumption of alcohol, naltrexone administration was associated with decreases in his drinking behavior. Before enrollment, (he) was drinking seven drinks per day, 7 days per week; during treatment, (he) averaged one drink per day, 2 days per week. When craving and alcohol consumption increased acutely during naltrexone therapy, (he) responded to dose escalations with decreased craving and alcohol consumption. In addition, (he) has not reported any craving for or use of heroin or cocaine during 30 weeks of naltrexone therapy.

Patient Background Information: (he) is a 30-year-old, single, black man who completed the 10th grade and last worked as a custodian in 1990. His longest term of employment was 5 months. He is currently pursuing a GED as a component of his program treatment plan. His drug use history began at age 16 with experimental use of diazepam (Valium). A year later, he began using intranasal cocaine and heroin (approximately $10.00 each per day) and marijuana (approximately $5.00 per day) daily. His alcohol use did not begin until age 27, at which time he was drinking three to four standard drinks per day. He was convicted on drug and weapons charges on three separate occasions and was incarcerated for a total of 38 months between 1986 and 1994. As a condition of his most recent parole, he was required to attend substance abuse treatment. During the 2 months between his release and study enrollment, (he) discontinued his heroin and cocaine use. However, during the same period he consumed seven drinks per day, 7 days per week in the form of beer and bourbon. His father was alcohol, heroin, and cocaine dependent with an unknown age of onset. one paternal uncle was also alcohol dependent. His mother did not use any alcohol or drugs, but three maternal uncles and his maternal grandfather were alcohol dependent. His two younger brothers do not use alcohol, but both are heroin and cocaine dependent. He has no significant medical or psychiatric history and has not received any concomitant medications during study participation.

Naltrexone Treatment and Results: (he) enrolled in our full-day psychosocial treatment program and initiated naltrexone treatment at 50 mg per day. During his first 12 weeks of treatment, his average craving score was 2, and he drank an average of one drink per day, 2 days per wee k. However, his craving and drinking increased during weeks 6 through 12, and he met relapse criteria on each biweekly visit during that period. This reemergence of drinking coincided with his transition to a half- day psychosocial treatment program. At week 12, his craving score had increased to 4 and he was drinking an average of seven drinks per day, 2 days per week. Interestingly, (he) reported no craving for heroin or cocaine during this period, and heroin and cocaine abstinence were confirmed through program urine toxicology screens. At the beginning of week 13, the study physician increased the naltrexone dose to 100 mg per day, and by the end of that week, (his) craving score and alcohol consumption had been cut in half. Although (he) responded acutely to this dose increase, his craving and alcohol consumption again increased through week 24. At week 24, his craving score was 6 and he was drinking an average of six drinks per day, 4 days per week. At the beginning of week 25, his naltrexone dose was increased to 150 mg per day, and by the end of that week (his) craving score and alcohol consumption were again cut in half. During week 28, (he) ran out of naltrexone and failed to report to the program site for additional medication. During this period, he reported an acute increase in craving and alcohol consumption. Craving was reduced upon reinstatement of medication at week 29, and the patient has achieved complete abstinence during weeks 29 and 30. The patient has not used heroin during this period and has had only one positive cocaine urine screen during nearly 8 months of program participation. The patient enrolled with normal liver function tests and these values have remained normal throughout his participation.

Naltrexone administration in this patient has been associated with complete abstinence from cocaine and heroin following a 13-year history of dependence on these drugs. Although the patient did not achieve alcohol abstinence, his drinking has decreased from a pre-enrollment average of seven drinks per day, 7 days per week to an overall average of one drink per day, 2 days per week during naltrexone administration.

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