Question 1

A 45-year-old man with alcohol use disorder asks about medication options. He is currently drinking 6-8 beers daily and is not yet ready to commit to complete abstinence, but he wants to reduce his drinking. He has no history of opioid use. His liver enzymes are mildly elevated (AST 55, ALT 60). Which medication approach is most appropriate?

Accepted Answer

Answer A (disulfiram) requires commitment to abstinence and creates a dangerous aversive reaction if the patient drinks, inappropriate for someone actively drinking who is not ready for complete abstinence. Answer C (acamprosate) is designed to maintain abstinence in patients who are already abstinent; starting it in an actively drinking patient does not match the medication's mechanism or evidence base. Answer D reflects an outdated abstinence-only philosophy; pharmacotherapy can help reduce drinking as a pathway toward recovery even before complete abstinence is achieved. The teaching point: naltrexone for AUD can be started while the patient is still drinking, and harm reduction (reducing drinking) is a valid treatment goal.

Question 2

A patient with OUD has been on Vivitrol (naltrexone ER 380mg IM) monthly for 8 months and is doing well. He decides to stop treatment. At his final visit, what is the single most important safety counseling point?

Accepted Answer

Answer A is incorrect, naltrexone is a pure antagonist with no physical dependence; there is no withdrawal syndrome on discontinuation. Answer C is not indicated if the patient is doing well and choosing to stop treatment (though ongoing MOUD may be discussed as an option). Answer D is reasonable general advice but not the critical safety point. The teaching point: tolerance loss after any period of opioid abstinence (including naltrexone-maintained abstinence) is a potentially fatal risk that must be explicitly addressed.

Question 3

A psychiatrist is explaining the difference between naltrexone and disulfiram for AUD to a medical student. She says: "Naltrexone makes drinking less fun; disulfiram makes drinking make you sick." Is this an accurate simplification?

Accepted Answer

Answer A ignores the fundamentally different mechanisms. Answer C is incorrect (naltrexone is FDA-approved for both OUD and AUD). Answer D reverses the mechanisms. The teaching point: the distinction between "blocking reward" (naltrexone) and "creating aversion" (disulfiram) illustrates two completely different pharmacological approaches to the same behavioral problem. Understanding this distinction is essential for matching the right medication to the right patient.

Naltrexone

Side Effects Worth Knowing

Nausea: the most common side effect

Headache: common

Injection site reactions (Vivitrol): common

Dizziness/fatigue: reported

Dysphoria/mood changes: reported

Hepatotoxicity: warning in labeling

Insomnia: reported

Decreased appetite: reported

See This Medication in Action

References & Further Reading