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Clinical Vignette: Substance Use Disorders (Alcohol) 

Clinical Vignette: Substance Use Disorders (Alcohol)
Chapter:
Clinical Vignette: Substance Use Disorders (Alcohol)
Source:
Psychiatry Board Review
Author(s):

Shirshendu Sinha

DOI:
10.1093/med/9780190265557.003.0043

A 45-year-old corporate lawyer presents for treatment of problem drinking. He tried alcohol for the first time at age 17, drank occasionally through college, and began drinking heavily in law school. He reports having at least 6 beers daily and drinks up to 14 drinks in a day. He often wakes up with hangovers and arrives late at work. He states, “I have this intense urge to drink and keep thinking about alcohol all the time.” He misses family events, has stopped playing tennis, and spends time at a local bar. His wife has threatened to move out with their children. He has been trying to cut down on his own but has not been able to do so. He denies any prior psychiatric diagnosis. Hee scored a 24 on the Alcohol Use Disorder Identification Test. He is eager to get help and has some insight into his problem with alcohol. He is interested in a treatment program.

1. Which of the following symptoms meet DSM-5 criteria for alcohol use disorder?

(Select all that apply)

  1. A. Daily drinking

  2. B. Failed attempts to quit

  3. C. Legal consequences

  4. D. Sacrifice activities due to use

  5. E. Failure at role fulfillment due to use

  6. F. Family history of alcohol use disorder

  7. G. Craving with compulsion to use

  8. H. Recent use of alcohol

  9. I. Alcohol Use Disorder Identification Test score of 7

  10. J. Use of alcohol in situations where it is hazardous

Answers

Answer: B, D, E, G, J

The symptoms (in parentheses) described here that meet the DSM-5 diagnostic criteria of substance use disorders include unsuccessful attempts to cut down or control use (failed attempts to quit); important social, occupational, or recreational activities are given up or reduced because of use (sacrifice activities due to use); recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (failure at role fulfillment due to use); a strong desire or urge to use (craving with compulsion to use); and recurrent alcohol use in situations in which it is physically hazardous (use of alcohol in situations where it is hazardous). DSM-IV-TR had separated use disorders into abuse and dependence, but these diagnostic criteria were combined in DSM-5 with some exceptions. Because presence of legal problems, which was a diagnostic criterion option in substance abuse in DSM-IV-TR, does not correlate with substance abuse or dependence, it was abandoned in DSM-5. Craving, defined as a strong desire to use a substance, was added as a new diagnostic criterion for substance use disorders in DSM-5.

Reference

American Psychiatric Association. (2013). Substance -related and Addictive Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., pp 481–589). Arlington, VA: American Psychiatric Publishing.Find this resource:

2. Results from the National Epidemiologic Survey on Alcohol and Related Conditions, a large epidemiological study in the United States, which targeted clivilian adults 18 years and older in household and selected group quarters, indicatewhich of the following? (Select all that apply.)

  1. A. Twelve-month prevalence of alcohol use disorder is about 14%.

  2. B. Alcohol use disorder is significantly associated with anxiety disorders.

  3. C. Lifetime prevalence of alcohol use disorder is about 30%.

  4. D. Lower income has an inverse relationship with prevalence of alcohol use disorder.

  5. E. Significant associations were found between 12-month and lifetime prevalence of alcohol use disorder and other substance use disorders, major depression, bipolar I disorders, and antisocial and borderline personality disorders.

Answers

Answer: A, C, E

A recent epidemiological study, known as the National Epidemiologic Survey on Alcohol and related Conditions-III (NESARC-III), aimed to identify the prevalence and correlates of DSM-5 substance use disorders. 36,309 in-person interviews were conducted on US civilians 18, years and older of households and selected group residential quarters. The 12-month and lifetime prevalence of alcohol use disorder was estimated at 13.9% and 29.1%, respectively. The 12-month and lifetime prevalences of severe alcohol use disorder was greatest among respondents with the lowest income level. Significant associations were found between 12-month and lifetime alcohol use disorder and other substance use disorders, major depressive and bipolar I disorders, and antisocial and borderline personality disorders. Associations between alcohol use disorder and panic disorder, specific phobia, and generalized anxiety disorder were modest.

Reference

Grant, B. F., Saha, T. D., Ruan, W. J., Goldstein, R. B., Chou, S. P., Jung, J….Hasin D. S. (2016). Epidemiology of DSM-5 drug use disorder: Results from the National Epidemiologic Survey on Alcohol and Related @ Conditions-III. JAMA Psychiatry 73 , 39–47.Find this resource:

3. What is the most likely diagnosis that has been presented here?

  1. A. Alcohol abuse

  2. B. Alcohol use disorder, mild

  3. C. Alcohol dependence

  4. D. Alcohol use disorder, moderate

  5. E. Alcohol use disorder, severe

Answers

Answer: E

For all substances including alcohol, the DSM-IV diagnoses of substance abuse and substance dependence have been replaced with a single diagnosis, substance use disorder. DSM-5 alcohol use disorder diagnosis required at least 2 of the 11 criteria in the 12 months preceding the interview. Per DSM-5, a mild alcohol use disorder is suggested by the presence of@numerals? see apa explanation for consistency within sent or par/ 2-3 criteria, moderate by@ 4-5 criteria, and severe by @6 or more criteria. The patient described in this vignette meets the diagnostic criteria for alcohol use disorder, severe.

Reference

American Psychiatric Association. (2013). Substance-related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed., pp 481–589). Arlington, VA: American Psychiatric Publishing.Find this resource:

4. The patient reports having significant urges to use alcohol. Which of the following scales has been used in research and clinical practice to measure urges?

  1. A. Alcohol Use Disorders Identification Test (AUDIT)@are abbs ok in these answers? see full in par below for some/

  2. B. Alcohol Time Line Follow Back (TLFB)

  3. C. Audit Alcohol Consumption Questions (AUDIT-C)

  4. D. CAGE - Adapted to Include Drugs (CAGE-AID)

  5. E. Penn Alcohol Craving Scale (PACS)

Answers

Answer: E

PACS is a 5-item, self-administered, instrument for assessing craving. Current craving is often used as a treatment outcome measure because it is frequently a signal of impending relapse. The@full first or second? AUDIT @same name ear in chap? is a 10-item questionnaire that screens for hazardous or harmful alcohol consumption that is suitable in primary care settings and has been used in a variety of populations and cultures. The@ TLFB is a drinking assessment method that obtains estimates of daily drinking retrospectively over a specified period. It can be used to provide feedback to increase motivation for change. The AUDIT-C is a brief @3-item questionnaire about hazardous drinking. The CAGE-AID (an acronym for cut down, annoyed, guilty, eye-opener) AID is a commonly used,@ five-item tool used to screen for drug and alcohol use.

Reference

Flannery, B. A., Volpicelli, J. R., & Pettinati, H. M. (1999). Psychometric properties of the Penn Alcohol Craving Scale. Alcoholism: Clinical and Experimental Research, 23, 1289–1295.Find this resource:

Schneekloth, T. D., Biernacka, J. M., Hall-Flavin, D. K., Karpyak, V M., Frye, M. A., Loukianova, L L.,… Mrazek D. A. (2012). Alcohol craving as a predictor of relapse. American Journal on Addictions, 21(suppl. 1), S20–S26.Find this resource:

5. Which of the following medications have been approved by the United States Food and Drug Administrtion (FDA) for the treatment of alcohol use disorder? (Select all that apply.)

  1. A. Fluoxetine

  2. B. Naltrexone

  3. C. Bupropion

  4. D. Gabapentin

  5. E. Acamprosate

  6. F. Topiramate

  7. G. Disulfiram

Answers

Answer: B, E, G

Naltrexone, acamprosate, and disulfiram have been approved by the @but abb used in question and elsewhere/ FDA for the treatment of alcohol use disorder. Naltrexone, is effective in reducing alcohol craving and preventing alcohol-induced relapse. Mu opiate receptor antagonism of naltrexone and resultant blocking of centrally mediated reinforcing effects of alcohol are proposed explanations for naltrexone’s effectiveness. It is available as a daily oral pill or as a monthly depot injection. Acamprosate is a small, flexible molecule that resembles GABA and decreases glutamatergic neurotransmission, by acting as an N-methyl-D-aspartate antagonist. It has been proposed that naltrexone helps sustain abstinence in detoxified alcohol-dependent individuals by reducing neuronal hyperexcitability during early recovery. Disulfiram inhibits the enzyme aldehyde dehydrogenase. When alcohol is ingested after disulfiram, toxic levels of acetaldehyde accumulate, leading to a host of unpleasant symptoms, which are deterrents to drinking alcohol.

Additional Reading :

Kleber, H. D., Weiss, R. D., Anton, R. F., Jr., George, T. P., Greenfield, S. F., Kosten, T. R.,…Connery H. S. (2006). Practice guidelines for the treatment of patients with substance use disorders. In Amerian Psychiatric Association’s practice guidelines for the treatment of psychiatric disorders (2nd ed., pp 491–589). Washington, DC: American Psychiatric PressFind this resource:

6. In addition to psychosocial interventions, which of the following medications is most effective for the maintenance of complete abstinence of alcohol? )

  1. A. Fluoxetine

  2. B. Naltrexone

  3. C. Bupropion

  4. D. Gabapentin

  5. E. Acamprosate

  6. F. Topiramate

  7. G. Disulfiram

Answers

Answer: E

Acamprosate was approved by the FDA in 2004 to treat alcohol dependence through preventing relapse and promoting abstinence. The best evidence for a pharmacotherapeutic agent in patients seeking to remain abstinent as opposed to reducing their drinking levels is for acamprosate. Length of abstinence following treatment with acamprosate has also been demonstrated to be associated with genetic variants in GRIN2B, the gene that encodes the GluN2Bsubunit of NMDA receptors.

Reference

Helton, S. G., & Lohoff, F. W. (2015). Pharmacogenetics of alcohol use disorders and comorbid psychiatric disorders. Psychiatry Research,230, 121–129.Find this resource:

Kleber, H. D., Weiss, R. D., Anton, R. F., Jr., George, T. P., Greenfield, S. F., Kosten, T. R., Connery H. S. (2006). Practice guidelines for the treatment of patients with substance use disorders. In American Psychiatric Association’s practice guidelines for the treatment of psychiatric disorders (2nd ed.). Washington, DC: American Psychiatric Publishing.Find this resource:

7. Which of the following FDA-approved medications used for treatment of alcohol use disorders is more effective if administered after a period of sobriety?

  1. A. Fluoxetine

  2. B. Naltrexone

  3. C. Bupropion

  4. D. Gabapentin

  5. E. Acamprosate

  6. F. Topiramate

  7. G. Disulfiram

Answers

Answer: E

Acamprosate was approved by the FDA in 2004 to treat alcohol dependence through preventing relapse and promoting abstinence. Data suggest that acamprosate presumably works best in controlling the desire to drink after a period of abstinence.

Reference

Helton, S. G., & Lohoff, F. W. (2015). Pharmacogenetics of alcohol use disorders and comorbid psychiatric disorders. Psychiatry Research, 230, 121–129.Find this resource:

Kleber, H. D., Weiss, R. D., Anton, R. F., Jr., George, T. P., Greenfield, S. F., Kosten, T. R., Connery H. S. (2006). Practice guidelines for the treatment of patients with substance use disorders. In American Psychiatric Association’s practice guidelines for the treatment of psychiatric disorders (2nd ed., pp. 481–589). Washington, DC: American Psychiatric Publishing.Find this resource:

8. Which of the following is available as a depot injection for alcohol use disorder?

  1. A. Naltrexone

  2. B. Gabapentin

  3. C. Acamprosate

  4. D. Topiramate

  5. E. Disulfiram

Answers

Answer: A

Naltrexone, a mu receptor antagonist, is available as a monthly depot injection under the trade name Vivitrol® and is approved for the management of alcohol use disorder and opioid use disorder.

9. Which of the following medications is effective in treatment for alcohol use disorder and relapse@hy? -related symptoms of insomnia, dysphoria, and cravings? )

  1. A. Valproic acid

  2. B. Fluoxetine

  3. C. Pregabalin

  4. D. Gabapentin

  5. E. Clozapine

Answers

Answer: D

Beneficial effects of gabapentin for the treatment of alcohol use disorder were found over the 12-week course of treatment on (A) the rates of complete abstinence and on rates of eliminating heavy drinking; (B) the number of heavy drinking days and the number of drinks consumed per week; and (C) severity of craving, insomnia, and dysphoria. Results followed a linear dose effect, with greatest efficacy achieved at the 1,800-mg dose. Laboratory measures of GGT provided validation of gabapentin’s effects on self-reported drinking outcomes. Significant effects were found to persist after treatment in study completers who participated in the follow-up assessment that was conducted 24 weeks after initial administration. Gabapentin was well tolerated, with no deaths and no drug-related adverse effects. Gabapentin has not been approved by the FDA for the treatment of alcohol use disorders.

Reference

Mason, B. J., Quello, S., Goodell, V., Shadan, F., Kyle, M., & Begovic, A. (2014). Gabapentin treatment for alcohol dependence: A randomized clinical trial. JAMA Internal Medicine, 174, 70–77.Find this resource:

10. During treatment in the residential facility, the patient agrees to take acamprosate to support abstinence. Which of the following laboratory tests should be obtained to determine the starting dose of acamprosate?

  1. A. Complete blood count

  2. B. Aspartate aminotransferase

  3. C. EKG

  4. D. Creatinine clearance

  5. E. Serum electrolytes

Answers

Answer: D

Acamprosate is generally well tolerated; diarrhea is the most common side effect. Because acamprosate is exclusively excreted by the kidneys, creatinine clearance should be monitored, and caution must be taken with patients who have renal impairment.

Reference

Saivin, S., Hulot, T., Chabac, S., Potgieter, A., Durbin, P., & Houin, G. (1998). Clinical pharmacokinetics of acamprosate. Clinical Pharmacokinetics, 35, 331–345.Find this resource:

11. The overactivity of which of the neurotransmitters produces symptoms of acute alcohol withdrawal?

  1. A. Serotonin

  2. B. Dopamine

  3. C. Glutamate

  4. D. GABA

  5. E. Norepinephrine

Answers

Answer: C

When alcohol is removed from the body of chronic heavy regular alcohol drinkers, a “hyperglutamatergic” state develops, which in combination with reduced GABA function produces excessive excitatory signaling, contributing to the potentially life-threatening alcohol withdrawal syndrome.

Reference

Holmes, A., Spanagel, R., & Krystal, J. H. (2013). Glutamatergic targets for new alcohol medications. Psychopharmacology, 229, 539–554.Find this resource:

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