What is the best course of action for a 27-year-old male with obsessive-compulsive disorder (OCD), anxiety, and a history of alcohol use disorder, who has refused non-stimulant and non-controlled medication for withdrawal symptoms and is seeking care elsewhere?

From the Guidelines

The best course of action for this 27-year-old male with OCD, anxiety, and alcohol use disorder who has refused non-stimulant and non-controlled medications is to refer him to a specialized dual diagnosis treatment program that can address both his mental health conditions and substance use disorder simultaneously. This patient would benefit from an integrated approach that includes cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) specifically for OCD, as supported by studies such as 1, which highlights the effectiveness of ERP in treating OCD. Along with motivational interviewing for alcohol use disorder, medication options that could be reconsidered include SSRIs like sertraline or fluoxetine for OCD and anxiety, as suggested by 1, which notes that SSRIs are the first-line pharmacological treatment for OCD due to their efficacy, tolerability, and safety. Non-addictive options for alcohol withdrawal such as gabapentin or topiramate could also be considered, and for alcohol withdrawal management, a medically supervised detoxification program may be necessary, potentially using benzodiazepines like chlordiazepoxide or diazepam on a tapering schedule under strict monitoring, as the patient has a history of severe alcohol withdrawal. The patient should also be connected with support groups like Alcoholics Anonymous and encouraged to build a support network, as this comprehensive approach is recommended because the co-occurrence of OCD, anxiety, and alcohol use disorder creates a complex clinical picture where each condition can exacerbate the others, and addressing all conditions simultaneously offers the best chance for recovery. Key considerations in managing this patient include:

• The importance of addressing both OCD and alcohol use disorder simultaneously for effective treatment, as noted in 1, which discusses the complexities of OCD and the need for comprehensive treatment approaches.
• The potential benefits of CBT with ERP in reducing OCD symptoms, as highlighted in 1.
• The role of SSRIs in treating OCD and anxiety, as discussed in 1, which emphasizes the efficacy and safety of SSRIs in OCD treatment.
• The need for medically supervised detoxification and support groups in managing alcohol withdrawal and promoting long-term recovery.

From the FDA Drug Label

PRECAUTIONS General Suicide Since depression is a commonly associated feature of OCD, the risk of suicide must be considered. The patient has a history of alcohol use disorder, OCD, and anxiety, and has refused non-stimulant and non-controlled medication for withdrawal symptoms. Given the patient's complex presentation and refusal of recommended treatment, the best course of action would be to:

• Refer the patient to a specialist, such as a psychiatrist, who can provide more comprehensive care and explore alternative treatment options.
• Ensure the patient's safety and well-being by providing crisis resources and emergency contact information.
• Document the patient's refusal of treatment and the reasons for referral to a specialist 2.

From the Research

Patient Background and Concerns

• Jason Trevino, a 27-year-old male, presents with significant anxiety and obsessive-compulsive disorder (OCD) symptoms, including compulsive repetitive behaviors.
• He has a history of using alcohol to self-medicate his anxiety and OCD symptoms, with a recent severe binge drinking episode resulting in hospitalization.
• Jason was discharged with a limited supply of chlordiazepoxide, which has caused him concern about managing his withdrawal and underlying symptoms.

Treatment Options and Considerations

• Jason has tried several medications for his OCD symptoms, including sertraline and fluoxetine, with limited success.
• He has also been prescribed trazodone for sleep issues, which he found ineffective.
• The use of gabapentin as a potential treatment option for anxiety disorders, including those with co-occurring substance use disorders, has been explored in several studies 3, 4.
• However, the effectiveness of gabapentin in treating OCD symptoms is unclear, with some studies suggesting no significant benefit 3.

Management of Withdrawal Symptoms

• Jason's recent hospitalization for alcohol withdrawal and his ongoing concerns about managing his withdrawal symptoms highlight the need for effective management strategies.
• The use of gabapentin as a substitution therapy for pregabalin use disorder has been examined, but preliminary findings suggest it may not be a suitable alternative 5.
• A systematic review of community health services for dual diagnosis treatment emphasizes the importance of integrated service assessment tools and evidence-based interventions 6.
• A case report highlights the need for patient-centered slow tapers in patients with severe gabapentin dependence and withdrawal, using a framework such as the BRAVO Protocol 7.

Next Steps

• Given Jason's complex presentation and history of treatment failures, a comprehensive treatment plan that addresses his anxiety, OCD, and substance use disorders is necessary.
• Further evaluation of Jason's symptoms and treatment history is required to determine the most effective course of action.
• Consideration of alternative treatment options, such as cognitive-behavioral therapy or other medications, may be necessary to address Jason's ongoing symptoms and concerns.