A case report by guest bloggers Richard Gray and Dr Tanzeel Ansari…
Note: Patient consent was given. Patient name has been changed for purposes of confidentiality
This write up is a single case report into the naturalistic use of nalmefene within a community alcohol treatment service in Nottingham. Nalmefene was given a European licence in 2012 and is intended to be used as a first line pharmacological therapy for the reduction of alcohol consumption in people over 18 years of age with alcohol dependence who are unable to achieve abstinence, or for whom reduction is a more appropriate goal. NICE guidelines CG115 recommends that everyone who fits the criteria for treatment is offered some form of pharmacotherapy. Medication is used for withdrawal and relapse prevention. (The latter include: acamprosate, naltrexone and disulfiram).
It is recognised that not everyone who seeks help for alcohol use want to be abstinent and for some a goal of moderate or “controlled drinking” can lead to more successful engagement. Following nalmefene being granted its UK licence we prescribed it to a patient at Oxford Corner, the statutory NHS community alcohol treatment base for Nottingham City, a recovery oriented specialist alcohol service. Our patient was seen for regular keyworking sessions to explore psychological interventions aimed at moderating his alcohol consumption, alongside the administration of nalmefene, as recommended in the BNF.
A 49 year old Caucasian male “Jonty” was referred in April 2013. At assessment he was consuming in excess of 250 units of alcohol each week. He was drinking standard strength lager (4%ABV), mainly in the evenings after work and all day at the weekends. He was concerned as he had started to drink in the mornings before work.
Jonty described drinking heavily all his adult life, used to drink 9%ABV lager but reduced this to 4%ABV lager following an episode of abdominal pain that may have been pancreatitis. There were no previous episodes of alcohol treatment and no ongoing physical health complications arising from his consumption of alcohol. He wanted to reduce his consumption, but not stop altogether. He also wanted to explore the changes to his lifestyle that this would necessitate.
He was asked to keep an alcohol consumption diary and to record the number of drinks he consumed each day. For simplicity, as he drank the same 4% ABV lager, he recorded number of drinks, which were then converted to units.
Table 1 shows his baseline consumption in the first two weeks of treatment. On 22nd April he was ill (acute abdominal pain) so didn’t drink at all, otherwise it followed a typical pattern. This gave us a benchmark to work from and he decided that he wanted to work on the morning and the weekday drinking. We set a target of 15 drinks per day during the week. Over the next four months we gradually reduced this target to 13 drinks (see table 2).
Following discussion with Jonty, we agreed to trial nalmefene from 18th October 2013. BNF recommends 1 tablet (18mg) taken as required on each day there is a risk of drinking alcohol. Our patient wanted to see if there was a difference in consumption levels on days with versus days without nalmefene. As he was drinking every day we agreed to try 1 tablet every other day during the week and not at the weekend.
Table 3 shows the number of drinks and days when he took nalmefene over the first two weeks of prescription. Table 4 shows the last two weeks taking nalmefene.
Figure 1 shows the number of drinks recorded in all diaries till the end of January 2014. Missing data is due to drink diaries lost by the patient, who reported that he continued taking the medication during this period. The time window when nalmefene was taken is recorded above the drinks graph.
At the first appointment following starting the medication Jonty stated that he had found it hard work taking it, mainly due to side effects. He described a “droning” in his head, difficulty sleeping, nausea and dizziness. He did feel that the medication had helped him reduce his consumption and that it had taken the “edge off”- that he was slowing down and didn’t feel like drinking alcohol more. Had been taking the tablet first thing in the morning and did find that the afternoons were particularly difficult. We agreed to switch it to lunchtime administration and continue to take every other day during the week.
By mid-December he described feeling worse, (in terms of the side effects) the day after taking the meds. We discussed whether alternate day dosing may be contributing to side effects. He was due to take some leave from work, and we agreed a subsequent change to daily dosing for two weeks (see table 4).
On 15th January 2014 he reported that he had stopped taking nalmefene on 5th January due to the continuing side effects. His primary concern was that he felt he wasn’t safe at work. He reported feelings that he was being watched all the time and that he was not able to do his job properly, constantly having to check his work and a sense that what he had just done was wrong. Some continued nausea, despite changes made to the way in which he had been taking the medication, was also present.
Interestingly, in the days immediately following stopping the medication he recorded his lowest level of consumption. He said that, without the assistance of medication, he would have to re-evaluate his own motivation in light of skills he had internalised in sessions. He had stopped drinking altogether in the mornings and took to consuming at a slower rate. His overall impression was that the drug had helped him to reduce his consumption by ultimately enabling him to improve his own level of motivation for change. And the overall trend line from the graph bears this out.
– Richard Gray, (author for correspondence) Clinical Nurse Specialist and Non-Medical Prescriber, Oxford Corner, Nottinghamshire Healthcare NHS Trust, Nottingham NG1 5BH.
– Dr Tanzeel Ansari, Consultant Addictions Psychiatrist, Oxford Corner, Nottinghamshire Healthcare NHS Trust, Nottingham NG1 5BH.
Nalmefene (Selincro®) for the reduction of alcohol consumption – first line pharmacological therapy for alcohol dependence, Horizon Scanning Centre, University of Birmingham, September 2012
NICE CG115 Alcohol dependence and harmful alcohol use, National Institute of Health and Clinical Excellence, 2011 http://guidance.nice.org.uk/CG115
Nalmefene, British National Formulary issue 66 (September 2013), page 327
NIHR Horizon Scanning Centre, University of Birmingham, September 2012
 British National Formulary, September 2013