Clinical Case 4 of 15 · ~590 words
Clinical Case No. 4. Alcohol Use Disorder Without Severe Physical Complications
Identifying the problem at a routine appointment
Peter is 52. He cooks in a small restaurant in Nanaimo, lives with his wife and repairs a boat with a friend on weekends. He visits his physician because of high blood pressure. He mentions alcohol without particular concern: a few cans of beer after a shift, sometimes more at weekends. The misunderstanding begins with the word "can." He usually means 473 mL of 7% beer: about 26 g of ethanol, or 1.94 Canadian standard drinks of 13.45 g each. [123]
Once volume and strength are clarified, actual consumption proves much higher than the initial estimate. Peter regularly drinks more than intended, has unsuccessfully tried to cut down, feels craving at the end of his shift and continues despite conflict at home. Four behavioural criteria are consistent with moderate AUD. [81]
He has no history of seizures, delirium or morning drinking to relieve tremor. Previously, he managed several days without alcohol or severe symptoms. Before reducing consumption, the physician assesses withdrawal risk, physical illnesses, sedating substances, home support and access to reassessment.
There is no depressive or manic episode. Sleep is light, with early waking temporally related to evening drinking. Peter denies opioids, benzodiazepines and sleeping medications. ALT is 48 U/L with an upper reference limit of 40; bilirubin and albumin are within reference ranges, and eGFR is 88 mL/min/1.73 m². The physician plans to reassess liver tests during treatment.
Treatment goals and medication choice
Peter wants less craving, more control and better sleep. They agree on an initial goal of reduced consumption, criteria for evaluating progress and a possible later transition to abstinence.
In the absence of opioids and clinical contraindications, they choose naltrexone: initially 25 mg daily, then 50 mg as tolerated. Before prescribing, the physician also asks about codeine and other opioids in combination analgesics: naltrexone blocks their effects and can precipitate withdrawal in opioid dependence. Naltrexone and acamprosate are first-line medications for ongoing AUD treatment. [81]
Consumption decreases in outpatient care, with early follow-up; severe withdrawal does not occur. Mild nausea develops in the first days. Peter keeps a brief calendar of drinking, craving and sleep. One moment repeatedly appears: the last half-hour of a shift, when fatigue coincides with the usual invitation from colleagues.
A counsellor works with this situation. Peter arranges to go home with a colleague who ends the evening without alcohol, and to eat dinner beforehand. At a family meeting, he and his wife agree to speak openly about craving and spending.
The course over a year
After two months, heavy drinking is less frequent, sleep improves and blood pressure is easier to control. After conflict at work, Peter again drinks far more than planned one evening. At his appointment, they examine the sequence of events, regularity of naltrexone use and the possibility of more frequent counselling.
In the fourth month, Peter chooses abstinence himself: he finds it easier to get through the evening without the first drink than to stop each time. Earlier work has helped identify risky situations and acceptable support.
A year later, his condition is stable. Naltrexone duration is reviewed in light of craving, tolerability and Peter's preferences. They retain an agreement for prompt reassessment if things worsen.
Treatment has taken place in the community from the start: the problem became visible during an appointment about blood pressure, and subsequent contacts combined physical health monitoring, AUD medication and work on familiar evening situations.