Michael, a 39-year-old male executive, came for treatment unsure if he had a problem with alcohol drinking. He reported that he drank daily but only after work, when he would have 5 to 7 drinks in the evening. He denied that drinking was a significant problem for him, but he did admit that on occasions he would drink more than he intended and that he had difficulty going a whole day without some alcohol to “wind down.” When Michael first presented for treatment, he was initially evaluated by a nurse practitioner and a psychiatrist, who found that, except for some mild elevation in blood pressure and difficulty sleeping, Michael was quite healthy. As part of the biopsychosocial evaluation, it was discovered that Michael’s drinking did take away time from his wife, who was very concerned that his drinking was getting out of control. Michael was also increasingly concerned that he had difficulty controlling his drinking.
During the first session, the doctor reviewed various treatment options with Michael, including residential treatment, 12-step group support, pharmacotherapy, and cognitive-behavioral treatments designed to reduce the risk for relapse. Since Michael did not see himself as an alcoholic and had no intention of ever giving up drinking alcohol, the doctor suggested that Michael attempt a program of controlled drinking with the use of medications. Michael enthusiastically endorsed this approach since it addressed his primary concern that he felt his drinking was not controlled and he wanted to avoid future problems. The doctor advised Michael to completely abstain from drinking for a couple of days before beginning to take a medication, naltrexone, to help control his alcohol craving and limit excessive drinking. The doctor advised Michael that the medication works best after a period of 3 or more days of complete abstinence. It was agreed that any days in which alcohol drinking exceeded 5 drinks would indicate that Michael was not able to control his drinking and the treatment goals of controlled drinking would have to be reassessed. To help relieve any withdrawal symptoms, the doctor also prescribed oxazepam to be taken as needed. After 3 days, Michael returned to the program and was prescribed naltrexone.
For the next 12 weeks, Michael met with the doctor once a month to review medications and met with the nurse practitioner each week, who reviewed his symptoms and monitored his use of alcohol. Michael reported that the naltrexone reduced his desire to drink and that, on days when he did drink, it was generally limited to 2 drinks or less. He felt much more in control of his drinking. As the nurse practitioner reviewed Michael’s physical and psychological health and his social functioning, she pointed out to Michael how his productivity at work and improved relations with his wife correlated with his adherence to attending treatment sessions and taking his medication and his reduced drinking. The nurse practitioner also discussed his view of his treatment with Michael, who stated that he felt very satisfied with his progress.
After 12 weeks, Michael reduced his visits to once every 2 weeks and, after 3 months, to just one visit per month with either the nurse or doctor. Six months into treatment, Michael canceled an appointment, which was rescheduled. When Michael met with the nurse after the missed appointment, she discovered that he had quit taking his medication and had begun drinking again. Evaluating his pattern of drinking since the last visit, the nurse discovered that, about 3 days after stopping the naltrexone, Michael’s pattern of drinking about 2 drinks per day escalated so that in about a week’s time he was drinking about 7 drinks per day every day. Michael had felt too embarrassed to come for his last appointment and remained quite upset with himself for drinking again. The nurse reassured Michael that she could understand his feelings of shame but that such relapses are common. She reported that she was happy he was back in treatment. The nurse reviewed Michael’s current biopsychosocial level of functioning and discovered that Michael now saw that drinking had a more profound effect than he had previously realized on his work performance, sleep patterns, and, most important to Michael, his relationship with his wife. This time Michael decided that alcohol drinking, even controlled drinking, was simply not worth it and he, together with the nurse, agreed on a treatment goal of abstinence and resuming his naltrexone use. After completing an ambulatory alcohol detoxification program, Michael began meeting with the nurse weekly for about a month. After a month of continuous abstinence, Michael continued to meet with either the nurse or doctor at monthly intervals. For the past 12 months, Michael has remained on the naltrexone and, except for a slip on his birthday, has remained abstinent.