Anti-craving pharmacotherapy — structured clinical viva · Psych Vivas

Prompt

You are the psychiatry registrar in the addiction clinic. A 55-year-old with alcohol dependence finished detox four days ago. His GP started naltrexone 50 mg yesterday. Today he reveals he still takes PRN codeine for chronic back pain and drank mouthwash last night 'to test myself'. LFTs: ALT 95, GGT 180. eGFR 42 mL/min. He asks whether to add acamprosate and disulfiram 'for maximum cover' like antibiotics. Defend immediate safety actions, agent-by-agent gates (opioids, liver, renal), COMBINE literacy, and a revised plan.

Interpretation

Reveal interpretation

Immediate safety. Stop naltrexone while opioids (codeine) continue — risk of precipitated withdrawal and blocked analgesia. Assess for withdrawal symptoms and pain plan with non-opioid strategies / specialist pain input. Mouthwash alcohol exposure is a red flag for impulsive testing; explore readiness and risk, not shame.[1][5]

Agent gates.

Naltrexone: restart only after confirmed opioid-free interval, consent, medical alert, and LFT-informed caution (elevated enzymes require clinical liver assessment — not automatic forever ban, but not casual start in active hepatitis/failure).[1][5]
Acamprosate: eGFR 42 suggests dose reduction or avoidance per product guidance — do not add full 666 mg TDS blindly.[1][3]
Disulfiram: do not stack 'for cover'; requires separate consent, supervision, alcohol education; impulsive mouthwash testing is a relative warning against aversive therapy until stability improves.[1][4]

COMBINE pearl. Naltrexone and medical management helped; acamprosate null in that design — combination is not automatic 'antibiotic cover'.[2]

Revised plan. Stabilise opioids/pain; psychosocial package (CBT/MET); choose one suitable agent after gates clear; early review; dual diagnosis and suicide risk screen.[1][6]

Escalating viva probes

Probe	Model point
Oral naltrexone dose	50 mg daily (optional 25 mg test days)
Acamprosate standard dose	666 mg TDS if kidneys allow
Disulfiram dose range	200–250 mg supervised
XR-NTX role	Monthly IM adherence formulation; still opioid-free
COMBINE acamprosate	Null in that design; meta-analyses still support in other contexts

Key points

Hard stop: naltrexone + ongoing opioids
Renal gate owns acamprosate
Disulfiram needs supervision and suitable psychology, not polypharmacy bravado
Quote COMBINE with design humility
Medication never replaces psychosocial care

[1] [2] [3] [4] [5] [6]

References

[1]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Am J Psychiatry, 2018.PMID 29301420
[2]Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA, 2006.PMID 16670409
[3]Rösner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev, 2010.PMID 20824837
[4]Fuller RK, Gordis E Does disulfiram have a role in alcoholism treatment today? Addiction, 2004.PMID 14678055
[5]Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA, 2014.PMID 24825644
[6]Connor JP, Haber PS, Hall WD Alcohol use disorders. Lancet, 2016.PMID 26343838

Interpretation

Reveal interpretation

Agent gates.

Naltrexone: restart only after confirmed opioid-free interval, consent, medical alert, and LFT-informed caution (elevated enzymes require clinical liver assessment — not automatic forever ban, but not casual start in active hepatitis/failure).[1][5]
Acamprosate: eGFR 42 suggests dose reduction or avoidance per product guidance — do not add full 666 mg TDS blindly.[1][3]
Disulfiram: do not stack 'for cover'; requires separate consent, supervision, alcohol education; impulsive mouthwash testing is a relative warning against aversive therapy until stability improves.[1][4]

COMBINE pearl. Naltrexone and medical management helped; acamprosate null in that design — combination is not automatic 'antibiotic cover'.[2]

Revised plan. Stabilise opioids/pain; psychosocial package (CBT/MET); choose one suitable agent after gates clear; early review; dual diagnosis and suicide risk screen.[1][6]

Escalating viva probes

Probe	Model point
Oral naltrexone dose	50 mg daily (optional 25 mg test days)
Acamprosate standard dose	666 mg TDS if kidneys allow
Disulfiram dose range	200–250 mg supervised
XR-NTX role	Monthly IM adherence formulation; still opioid-free
COMBINE acamprosate	Null in that design; meta-analyses still support in other contexts

Key points

Hard stop: naltrexone + ongoing opioids

Renal gate owns acamprosate

Disulfiram needs supervision and suitable psychology, not polypharmacy bravado

Quote COMBINE with design humility

Medication never replaces psychosocial care

[1]

[2]

[3]

[4]

[5]

[6]

References

[1]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Am J Psychiatry, 2018.PMID 29301420
[2]Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA, 2006.PMID 16670409
[3]Rösner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev, 2010.PMID 20824837
[4]Fuller RK, Gordis E Does disulfiram have a role in alcoholism treatment today? Addiction, 2004.PMID 14678055
[5]Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA, 2014.PMID 24825644
[6]Connor JP, Haber PS, Hall WD Alcohol use disorders. Lancet, 2016.PMID 26343838