Summarization of the Clinical Case

Clinical History
Reggie is a 42-year-old African American male recently referred for outpatient psychotherapy by his PCP. While he is in relatively good health, he admitted to his doctor that he has been drinking alcohol excessively again over the last three months. Reggie had a problem with alcohol when he was in his twenties, but with the help of AA and his first male partner, he was able to cease drinking for the last 19 years. Reggie admits that it has not always been easy for him to abstain, but he is committed to trying again. He has attended AA meetings but has not been able to maintain complete sobriety. On average, he has one or two drinks nearly every evening. His partner, Bob, has a zero-tolerance policy for Reggie’s drinking and has moved in with a friend rather than deal with Reggie’s promises to stop. Reggie is worried that Bob may not come back. Reggie does not want to end up like his father, who drank himself to death at the age of 56. His father and mother divorced when Reggie was only 15. Reggie’s only sister had a serious addiction to benzodiazepines and spent 28 days in a rehab center. She is clean now but also abuses alcohol on occasion.
Postcase Discussion and Diagnosis
Reggie has Alcohol Dependence in Sustained Partial Remission with Moderate Symptoms (F10.20) He clearly shows signs of dependence and abuse as he continues to use alcohol despite the effect it is having on his relationship. He admits that coworkers have commented on his being late to work and that they have noticed alcohol on his breath. He has now taken to chewing gum to mask his alcohol breath and working longer hours to justify his lateness in the morning.
Psychopharmacological Treatment
At the urging of his family doctor and friends, Reggie has agreed to attend 90 meetings in 90 days. He now attends only gay AA meetings so he can feel more comfortable sharing aspects of his relationship with Bob without strange looks or criticism. Reggie also agreed to try Campral at the suggestion of his doctor. Reggie typically dislikes taking any medications, so his dose was started low (1000 mg qd). His dose was slowly raised to 2000 per day, and he reported that he was tolerating it without side effects. Reggie did not immediately crease drinking, but by the end of the first week he reported a tremendous drop in both his interest in alcohol and the enjoyment of drinking while engaging in drinking. He thought at first that he was losing interest in drinking whiskey, so he switched to beer. He later lost interest in beer and reported several days without alcohol. In a follow-up appointment with his PCP after six weeks on the medication, he reported that he celebrated 30 days sober and was on his way to the meeting to get his 30-day chip. He admits he has a long road to a sustained recovery, and he believes that Campral has helped him take the first serious steps and, with Bob’s forgiveness, he is taking one day at a time.
Remember to answer these questions from your textbooks and clinical guidelines to create your evidence based treatment plan. At all times, explain your answers.
1. Summarize the clinical case.
2. Create a list of the patient’s problems and prioritize them.
3. Which pharmacological treatment would you prescribe? Include the rationale for this treatment.
4. Which non-pharmacological treatment would you prescribe? Include the rationale for this treatment.
5. Include an assessment of treatment’s appropriateness, cost, effectiveness, safety, and potential for patient adherence.