Alcohol dependence treatment: Case studies in medication use

Expanding knowledge of how medications may interact with and complement counseling will help the addiction counseling community optimally coordinate care of patients with other treatment providers. Thus, this article series not only provides the latest efficacy and safety data on these medications, it also explores how we can build better relationships among addiction professionals and medication prescribers.

Previous articles in this series addressed the topics of facilitating the process of change through medication use; examining recent research on the approved medications for alcohol dependence; overcoming biases against greater use of medications in treating alcohol dependence; integrating medication into nonprescribing clinicians' treatment planning; and improving prescriber and nonprescriber collaboration to benefit the alcohol-dependent patient. In this final article, Carlo C. DiClemente, PhD, ABPP, presents case studies that illustrate how medications have helped individuals break their dependence on alcohol.

We would like to hear from you on what you thought of this article series, and on how the emergence of medications to treat alcohol dependence has affected your organization and your patients. Send your comments to genos1@cox.net; we may use them as letters to the editor in an upcoming issue.

This article series has covered a number of issues concerning the use of pharmacotherapies as part of a comprehensive approach to the treatment of alcohol dependence. The potential benefits of medication use, as well as its potential drawbacks if not used and managed properly, have been described in detail in this series. There is perhaps no stronger affirmation of the benefits of combining medications with counseling than seeing and hearing about actual patient experiences. Often counselors have concerns about medication use and have some examples of patients who did not take the medication or for whom the medication may not have been helpful. There is another side of the coin. This article focuses on how medications have been helpful in overcoming addiction in the stories of four women, each with a unique background and compelling story about how alcohol has affected her life.

There are similar stories of successful medication use in alcohol-dependent men, but the experiences of the four women profiled here were chosen because each used one or more of the approved medications for alcohol dependence treatment—acamprosate, disulfiram, oral naltrexone, and extended-release injectable naltrexone—and their experiences highlight different points about the various paths individuals take on their journeys to recovery. These women describe how these medications contributed to their recoveries by removing physical distractions (such as craving), which allowed them to focus on the counseling they received and channel their efforts into working through the various tasks of the stages of change and making the necessary changes in their drinking behavior. All of them describe how counseling helped them learn valuable skills to maintain their sobriety, and caution that medication use alone would not have given them the needed insights and skills for sustained recovery.

Other themes of this article series, such as the stages of behavior change through which recovering individuals transition, the biases patients face with regard to medication use, and the necessary collaboration between treatment providers and support groups, are prominent in these patients' stories.

Nikki

Nikki is a 27-year-old woman whose family had an extensive history of alcoholism and some drug use. Nikki began drinking alcohol and using marijuana when she was 11, and by age 20 she was also using heroin and crack cocaine. Her life was in disarray as a result of her addictions: She married a man she hardly knew, was forced to give up her children from previous relationships, and was convicted of four felony thefts within one year. Nikki entered inpatient treatment, which consisted of detoxification and group and individual therapy. Though diagnosed with bipolar disorder at age 12, Nikki only first began using medication for bipolar disorder during this treatment episode. This medication helped her bipolar symptoms; however, her addictions were still powerful and produced “very strong urges,” including dreams of drugs and alcohol and a continual taste of them in her mouth.

Over the next two years, Nikki entered and left eight different detoxification centers and halfway homes. In 2002, she began working with a new psychologist who recommended oral naltrexone in addition to her bipolar medications. Initially, Nikki had been unwilling to stop drinking, and the thought of using medications to treat her dependence was not appealing. Her treatment program consisted of regular employment during the day, once-weekly individual counseling (more frequent if she desired), twice-weekly group counseling, and four additional meetings with peers and counselors each week. She also began using oral naltrexone. Each of Nikki's daily naltrexone doses was supervised for three months, and within that time, she said her cravings for alcohol and drugs were lessened. “When the cravings were curbed, I was able to focus on myself and the core of my addiction—and the treatment program,” she reported. Nikki said these medications were the only way she could “begin my fight to recovery. Naltrexone did not cure my addiction or alcoholism, but it helped with the strength for me to begin the lifelong process.” She did not experience any significant side effects from naltrexone, and taking medication daily became “second nature” because of the routine that had been established when her dosing was monitored.

Nikki used naltrexone for a little over a year. She continues to use her medications for bipolar disorder daily. As is common with many recovering individuals, Nikki relapsed one time while on addiction therapy medication, but during this relapse she reported that she did not “feel any of the high” from the alcohol and drugs because their effects were blocked by naltrexone. That relapse was over three years ago, and it was the last time Nikki used alcohol or drugs.

Jennifer

Jennifer is a 38-year-old single mother of two. She began drinking alcohol at age 8 and was drinking heavily by the age of 14. Her father was an alcoholic, and she drank to “escape” from the trauma of having been sexually abused as a child. She used marijuana in college and married shortly thereafter a man who was abusive and dependent on alcohol.

When Jennifer became pregnant, she stopped drinking alcohol, but after the birth of her child, she began using Vicodin® (hydrocodone and acetaminophen) on a regular basis to “numb” pain from marital and other life problems. After her divorce, Jennifer began drinking again, mixing about six beers every night with Vicodin. Soon Jennifer became obsessive about obtaining Vicodin: She planned how to get it, constantly counted the number of pills she had, and was distracted from work and daily activities by this obsession. It was not until she took 44 Vicodin over two days and almost fell asleep driving while intoxicated (from Vicodin) that she sought help.

Jennifer began seeing a mental health counselor, who recommended she get a formal assessment of her addictions. She began an eight-week intensive outpatient program and stopped drinking alcohol and using Vicodin for about seven months. However, she subsequently relapsed, abusing both alcohol and Vicodin, which she felt served as a crutch to deal with personal difficulties. After this relapse, she was prescribed oral naltrexone and disulfiram. Jennifer had not known that medications were available that might help her drinking (or drug addiction), and she was initially resistant to them because they “closed the door” on any opportunities to abuse drugs. Disulfiram, in particular, acted as a strong deterrent because Jennifer reported being afraid when she learned she could get sick from alcohol while taking the medication. In spite of her reservations, Jennifer began taking oral naltrexone and disulfiram. She reported that disulfiram essentially made her “stop thinking about alcohol.” She did try taking Vicodin while on naltrexone, but said she didn't get the high from it.

Jennifer took her medications every day under supervision of her counselor or a friend, which she said helped her overcome the challenge of making a decision to take her medications every day. In addition, Jennifer had to combat pressure from peers in her outpatient therapy group, because they intimated she was weak for using medications. Jennifer said her counselor helped her overcome these biases.

Jennifer has been sober for 21 months now and still goes to a women's health group and keeps her medications on hand. She credits her counselor for researching and suggesting medications as a part of treatment and referring her to a prescribing psychiatrist. Interestingly, Jennifer noted that rather than instantly recommending medication, her psychiatrist deliberately assessed Jennifer's commitment to changing her behavior and required her to learn about the medications before using them.

Karen

Karen is a 37-year-old woman who started drinking regularly in high school. There is a family history of alcoholism, and Karen's paternal grandfather was killed when he fell off a ladder, which her family believes was likely because of his drinking. Karen's adult life revolved around drinking, as her husband, his family, and several of their friends also drank heavily. For Karen alcohol was “performance-enhancing” because she was usually shy, and alcohol allowed her to socialize better, a trait that helped her work in sales. Her ability to drink large amounts—a 12-pack of beer a night, or three to four bottles of wine, or beer plus six to seven mixed drinks—became almost a “source of pride.”

About four years ago Karen's employer suspected she had a drinking problem, and voiced concern to her. Subsequently, Karen tried to stop drinking on her own but became very sick. She returned to drinking but was embarrassed, as indicated by her special efforts to “get rid of the evidence” of her drinking. She passed out one night and left her dog outside, and in the morning yelled in frustration at her dog for being outside all night. Karen felt she had hit bottom.

Karen had become so tolerant of alcohol that when she drove to the treatment center the day after a night of heavy drinking, her blood alcohol level was 0.4%. She underwent detoxification and began outpatient counseling, which consisted of group therapy three to four times a week and individual therapy when Karen desired it. She also started 12-Step therapy, initially five to six times a week and later once per week.

About two to three months after detoxification, Karen was offered acamprosate because of its track record in some European studies and its recent approval in the United States. Karen had had difficulty controlling alcohol cravings that were triggered by her environment. Certain cues, such as the sound of a popping bottle or beer can, smells, and associations of alcohol with certain meals and daily activities, were all positively associated with alcohol. Hearing stories of alcohol at 12-Step therapy meetings even stimulated cravings. In an effort to curb cravings cued by her environment, Karen had moved furniture around in her home to make it look like a new place. With the use of acamprosate, though, Karen said cravings and thoughts of alcohol stopped “entering her mind,” and her surroundings no longer made her desire alcohol.

Karen stressed that acamprosate was helpful to her only in combination with counseling. She cited a time when she was unable to have acamprosate for several days and was tempted to drink, but the coping skills she developed in therapy helped her overcome her temptations. On the other hand, Karen said acamprosate also improved her ability to attend group therapy, because hearing about alcohol was no longer a trigger while taking medication.

During group therapy, Karen faced peers who thought medications were a form of “cheating,” and she recommended that no one think of medications as a “magic bullet” that alone can cure addiction. Karen had little difficulty taking acamprosate, though she occasionally missed her midday dose of medication (dosed three times a day). She currently keeps different pill bottles in different locations in case she forgets a dose. Karen has not experienced any side effects, but she noted she felt more irritable and less able to handle stress when not taking the medication. She has recently celebrated her first anniversary of sobriety.

Nancy

Nancy is a 43-year-old single woman who did not drink much in her early adult life and had no strong family history of drinking. Nancy's drinking slowly escalated in her 20s. As a hostess in a restaurant, she was surrounded by alcohol, and she began drinking more frequently, making excuses about why she should drink. Nancy also described her drinking as a way to “numb the pain” and sadness she had long felt over the early death of her younger sister and later the untimely death of her older sister. This depression pervaded Nancy's daily life, and consequently she often drank alone and used alcohol to help her sleep at night.

Soon Nancy was drinking almost a quart of vodka daily, she no longer was working, and her drinking was sabotaging her marriage. Her husband filed a restraining order, which she violated. Ultimately, she was arrested three times for this and other alcohol-related violations. Nancy's dependence on alcohol had become so profound that she drank to avoid the shaking she experienced when she wasn't drinking. About three years ago, Nancy's primary care doctor prescribed an antidepressant for Nancy, which she used inconsistently. She also briefly tried Alcoholics Anonymous but admitted she was not ready to stop drinking. Her husband later divorced her, and her children distanced themselves from her.

Nancy entered rehabilitation over two years ago, but still she was not ready to quit drinking. She had been given acamprosate after this first detoxification, but she took the medication only once in a while and did not follow through with outpatient counseling or 12-Step therapy. She resumed drinking heavily, and a short time later tried to stop drinking on her own. Her abrupt abstinence resulted in a seizure that left her unconscious for five days. After her recovery, she resumed drinking again, went to rehabilitation for a second time, and made little progress.

Her primary care doctor suggested Nancy try extended-release injectable naltrexone. They read that counseling was a necessary component to treatment, which prompted Nancy to attend AA for three weeks before receiving her first dose. In addition, she resumed taking an antidepressant. Nancy asked a woman whom she had met briefly at an AA meeting years earlier to be her sponsor, because she recalled how happy this woman had been and she wanted to feel that happiness. Nancy received her first injection of extended-release naltrexone and was sober for a month but still had some temptation to drink. With the help of her sponsor and her parents' support, Nancy maintained her sobriety and continued with the medications. Nancy said that her weight returned to normal, that she had more energy and “a better outlook on life,” and that she was more willing to ask for help than in the past. She began attending school for medical billing and continued going to AA about three times a week. She moved into her apartment, and with continued sobriety she reconnected with her children.

In describing her experience with injectable naltrexone, Nancy said the medication gave her “an extra push” not to drink. After a while, she no longer had cravings or a desire to drink. Nancy said that having a scheduled monthly injection reminds and reaffirms her commitment to treatment. She described the injection as a bit uncomfortable, but she claimed to not have any side effects. Though she does not talk much about her medication use at AA, she said no one has criticized her for using medications if she does mention it. She has recommended injectable naltrexone to peers. Nancy said the combined treatment of AA and her medications has changed things for her completely. She has been abstinent for over a year and said she has never been happier.

Conclusion

Medication may not be a viable option for some patients or patterns of drinking. However, these examples indicate clearly that currently approved medications can assist alcohol-dependent individuals to achieve and sustain sobriety. While all of these patients acknowledged medications helped them achieve sobriety, they all said medications would not have worked without counseling. Working with a counselor, psychiatrist, psychologist, and peers helped each patient learn how to deal with her cravings and change her behavior so that alcohol and drugs were no longer an unhealthy coping mechanism for day-to-day problems.

Although each of these patients largely credits her success to the support she received, all of them share a persistent commitment and determination to change their unhealthy behaviors. This motivation and strength were vital to their recovery and are necessary for all dependent individuals to achieve sobriety. I want to thank Nikki, Jennifer, Karen, and Nancy for sharing their experiences, and hope you find their experiences instructive to your own practices.

Supported by an educational grant from Alkermes, Inc., and Cephalon, Inc.