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Difficulty: MediumSubstance-Related and Addictive Disorders

A 32-year-old woman comes to the clinic seeking help to stop drinking alcohol. She reports drinking 1 to 2 bottles of wine every evening for the past year. She tried to quit two days ago but experienced severe cravings, anxiety, and mild tremors, leading her to resume drinking. She also reports feeling severely depressed, with low energy, poor concentration, and feelings of worthlessness for the past month. Her psychiatric history is notable for a hospitalization three years ago due to an episode of severe agitation, rapid pressured speech, grandiosity, and a lack of need for sleep lasting 10 days. Her medical history includes chronic low back pain, for which she takes tramadol on an as-needed basis; she last took a dose this morning. Physical examination and laboratory studies, including liver function tests and serum creatinine, are within normal limits. Which of the following is the most appropriate pharmacotherapy regimen for this patient?

  1. Quetiapine and acamprosateAnswer
  2. B
    Sertraline and acamprosate
  3. C
    Lurasidone and naltrexone
  4. D
    Fluoxetine and naltrexone
  5. E
    Quetiapine and disulfiram

Answer

The most appropriate regimen is quetiapine and acamprosate.
The correct combination pairs an atypical antipsychotic (quetiapine) with an NMDA receptor modulator (acamprosate). Quetiapine is FDA-approved for acute bipolar depression and avoids the risk of precipitating mania associated with standard antidepressants. Acamprosate is a first-line treatment for Alcohol Use Disorder that helps maintain abstinence. Because acamprosate does not act on opioid receptors, it is safe to use in a patient taking tramadol. Furthermore, her normal serum creatinine indicates no contraindication to acamprosate, which is renally excreted.

Step-by-Step Solution

1
Diagnose the patient's mood disorder and identify safe pharmacotherapy.
The patient has Bipolar I Disorder currently in a depressive episode. Atypical antipsychotics like quetiapine or lurasidone are indicated, while SSRI monotherapy must be avoided.
The history of a 10-day hospitalization for grandiosity and decreased need for sleep indicates a past manic episode. Antidepressant monotherapy can precipitate a manic switch.
2
Diagnose the substance use disorder and identify concurrent medications.
The patient has severe Alcohol Use Disorder (AUD) and is actively taking tramadol (an opioid) for chronic pain.
Recognizing concurrent opioid use is critical for selecting safe AUD pharmacotherapy.
3
Select the appropriate AUD medication that avoids drug-drug interactions.
Acamprosate is the safest choice. Naltrexone is contraindicated due to tramadol use, and disulfiram is unsafe given her active drinking status.
Naltrexone is a mu-opioid antagonist and will precipitate severe withdrawal if given to a patient taking opioids. Acamprosate is safely metabolized via the kidneys and does not interact with opioids.

Key Concept

Pharmacological management of concurrent Alcohol Use Disorder and Bipolar I depression, emphasizing the avoidance of SSRI monotherapy and contraindications of naltrexone in patients taking opioids.
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Topics

Substance-Related and Addictive Disorders

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