Case Study 1

Presenting Complaint:    My wife, my family, and my friends would be shocked if they knew how much I drink or even that I drink. I maintain an "abstinence facade"around them. I do this because two of my children drink to excess and I'm always preaching for them to cut down. I feel very guilty that I am a hypocrite, and I know better because I am a doctor. My marriage would be over if my wife found out.

Patient History:     This is a 70 year-old white retired physician who was self referred from a newspaper ad in April 2000. He has been married for 45 years, and has three grown children, two of whom are reported to drink to excess. He lives in Sarasota for three months each year and returns to his primary residence in a mid-western state. He has used alcohol on a daily basis for more than 20 years, increasing significantly in the last eight years. He reports maintaining an "abstinence facade" around his wife, family, and friends. He reports consuming 8 to 16 ounces of vodka daily.  His clinical diagnosis Axis 1 is 303.90, with Axis IV, severe and Axis V, 75.

He requested a 30-day outpatient program to be completed before returning to his home state where he would continue counseling. His initial goal was the elimination of the intense craving, and his long-term goal was abstinence. He refused detox and would not agree to the immediate discontinuance of drinking.

He reports being unable to sleep without sneaking 6 to 8 ounces of vodka after his wife has gone to bed, and says that often he will lie in bed listening to her breathing for several hours until he is convinced she is sleeping soundly, then go to where his bottles were hidden and drink the remainder of the bottle. He also reports getting up very early in the morning and fixing her "breakfast in bed" which gives him a chance to drink privately in the kitchen. He reports that the anticipation of getting the alcohol is overwhelming. He drinks out of the bottle.

Naltrexone Treatment Results:         Overall, the client is healthy, although he has elevated hepatic enzymes. The client was prescribed Naltrexone, 50 mg, to be taken daily, psychological evaluation, and counseling. He reported symptoms of depression but refused mediation therapy. He was prescribed a low dose tranquilizer to help him sleep throughout the night. He is very motivated, and agreed to measure his alcohol prior to pouring it into a glass. During the first week he reported his alcohol consumption was reduced to one ounce per day, and he reported a reduction of 50 to 75 percent in his early evening craving. During the second week, adjustments were made to his medication regime, and he reported that his obsessive-compulsive drinking patterns were changing significantly. He was seen three times a week by a therapist and weekly by the physician. At the end of the third week, he reported his alcohol consumption had been reduced to zero. He reported that his natural sleep was improving, and his anxiety and depression also improving. He discontinued the evening sleep medication.

At discharge after four weeks, he reported abstinence and had zero craving both in the morning and evening hours that previously had been a significant problem. He agreed to continue the Naltrexone therapy with his own physician. He reported still feeling guilty and remorseful over his previous deception.

Follow-up interview:          One and two years later, the client reports that he continues in abstinence with zero alcohol craving. He reports  he implemented several lifestyle changes including increasing his exercise which he feels is beneficial to maintaining sobriety and reducing depression. He is "delighted" with the program results.